Cns pharmaceutical compositions and methods of use

ABSTRACT

The present invention is directed to CNS pharmaceutical compositions and methods of use. The pharmaceutical compositions comprise a CNS active agent and preferably at least two vagal neuromodulators, one of which is a mechanoreceptor stimulator. The vagal neuromodulators are preferably in an amount sufficient to reduce a somnolence side-effect of the CNS active agent without changing its therapeutic efficacy/activity. The invention further encompasses a method of reducing CNS active agent side-effects. The method typically comprises oral administration of at least one CNS active agent to a patient at the conventionally accepted dose; and administration of at least two vagal neuromodulators to the patient so that at least one neuromodulator is administered or released from dosage form after the CNS active agent is administered and/or released.

CROSS-REFERENCE TO RELATED APPLICATION

This patent application is a continuation-in-part of InternationalApplication No. PCT/IB2009/000309, filed Feb. 20, 2009, which is basedon and claims the benefit of U.S. Provisional Patent Application Ser.No. 61/030,141 filed on Feb. 20, 2008, the contents of each of which arehereby incorporated herein by reference for all that it discloses.

FIELD OF THE INVENTION

The present invention is directed to pharmaceutical compositions ingeneral, and more particularly to vagal afferent neuromodulators used incombination with a central nervous system (CNS) active agent as anadjunctive to reduce side effects associated with CNS agent withoutaffecting its therapeutic efficacy.

BACKGROUND

Various pharmaceuticals, such as CNS active agents cause severeside-effects that generally worsen with increasing doses. Some classesof CNS active agents that require increasing doses include pain reducingdrugs, selective serotonin re-uptake inhibitors, antidepressants,anti-convulsants, hypnotics, anesthetics, sedative agents, angiolytics,NSAIDs, xanthines, antipsychotics, appetite suppressants, sleep agents,antibiotics, antivirals, insulin resistance drugs, antihypertensives,and anti-asthma drugs. At high doses, many CNS active agents rapidlylose their effectiveness, induce pharmacologic tolerance, and causeincreasingly severe side-effects. Lowering the dose of the CNS activeagent, however, does not address the problem because reducing the doseto prior levels results in significantly lower therapeutic efficacy.

Combinations of centrally active agents have been used in an effort toovercome the current disadvantages of single agent use. In localanesthetic formulations, locally acting adrenergic agonists, such asepinephrine, are known to enhance the local activity of analgesic drugsand improve therapeutic efficacy. For example, it has been demonstratedthat a higher dosage of epinephrine potentiated the effects of localanesthesia. (Morganroth et al. 2009). Furthermore, several selective β2agonist drugs have been used in anesthesia, either alone or incombination, with various opiate or inhalational anesthetics, and havebeen found to reduce the dose requirement for opiates, halothane, orketamine (Verstegen 1989; Nevalainen et al. 1989; Moens and Fargetton1990). Additionally, U.S. Pat. No. 5,605,911 discloses the use of an β2agonist to block the neurotoxic effects, such as hallucinations andneuronal damage, of an NMDA antagonist. Similarly, U.S. Pat. No.6,562,855 teaches that co-administration of an NMDA receptor antagonistand an β2 adrenergic agonist both potentiates the effects of anesthesiaand diminishes the side effects compared to administration of anesthesiaalone.

U.S. Pat. No. 6,833,377 teaches that the activity of systemicallyadministered CNS drugs may be significantly potentiated by theco-administration of a compound which affects peripheral chemoreceptors(i.e. pseudoephedrine (PSE)) and a stimulator of osmoreceptors(osmoactive polymers or sorbitol). This potentiation results in areduction of the minimal effective dose of a variety of CNS activeagents, which in turn reduces the associated side effects.

Such combinations, however, are not without their problems. Thus, therestill exists a need for novel combinations of CNS active agents andneuromodulators to potentiate the pharmacological effect of the CNSactive agent, reduce dose-dependent side-effects, avoidtolerance/tachyphylaxis problems, and overcome the resistance andnoncompliance issues.

More specifically, there is a clinical need to develop “non-sedating”GABA agonists for therapeutic activities where sedation-related sideeffect damages the quality of life and cognitive functioning of thepatient, causing the patient to live most of the day in a daze andmaking it dangerous to drive vehicles and operate machinery. However,attempts to develop these “non-sedative” benzodiazepines have failed asthe prior art teaches that sedation effects of benzodiazepine treatmentare linked to the GABA-inhibiting therapeutic activity. In addition,attempts have been made to develop non-sedating anxiolytic drugs bychemical modification of the active agent, but no benzodiazepinereceptor partial agonist has emerged as a viable alternative.

The optimal anxiolytic drug product will be capable of producing arobust anxiolytic action by having a more rapid onset of action thancurrent therapies while potentially reducing the number of side effects.This drug would be comparable to benzodiazepines, but lacking theirlimiting side effects at therapeutic doses. This new drug wouldrepresent an important advancement in the treatment of anxietydisorders. Even if it is possible that a new, chemically-modifiednon-sedative GABA agonist may be finally developed, there is anadvantage in the utilization of a drug product combination from known,approved, and available pharmaceutical ingredients. Such an approachreduces the risk of potential unknown toxicity, and the long termdevelopment investment required of new pharmaceutical ingredients.

In light of the prior art, the inventors surprisingly discovered that(1) the reduction of sedation-associated side effects of CNS activeagents is possible using the conventional dosage of the CNS drug; (2)chemoreceptor stimulators (i.e. pseudoephedrine (PSE) and otherandrenergic receptor agonists) optimally reduce the side effectsassociated with a CNS agent when a mechanoreceptor stimulator (i.e.guaifenesin (GUA)) is administered approximately 15 minutes afteradministration of the CNS agent and PSE; and (3) administration of GUAeliminates the need to use a very high dose of osmoactive polymers (orother osmoactive agents) which can complicate formulation preparationand disturb the subject's physiological osmotic balance.

SUMMARY OF THE INVENTION

The present invention is directed to pharmaceutical compositionscomprising a central nervous system (CNS) active agent and method ofuse. The compositions and method advantageously reduce a side effect ofthe CNS active agent. In a preferred embodiment, the compositionsfurther comprise at least two vagal neuromodulators; and apharmaceutically-acceptable vehicle, carrier or diluent. The vagalneuromodulators are in an amount sufficient to reduce a side-effect ofthe CNS active agent. Preferably, at least one of the vagalneuromodulators is a mechanoreceptor stimulator. Suitablemechanoreceptor stimulator may be selected from the group consisting of:mucomodulators and surfactants, e.g., guaifenesin (GUA).

In addition, preferably that the vagal neuromodulators further compriseat least one chemoreceptor stimulator, and more preferably, at least onechemoreceptor stimulator selected from the group consisting of: pHmodulators, secretagouges, adrinomimetics, xanthines, cholecystokininsand gastric agonists, e.g., pseudoephedrine (PSE).

Advantageously, the present composition may further comprise a GABAmodulator and/or a nociceptor stimulator. In an exemplary embodiment,the vagal neuromodulator comprises a vasoactive agent and themechanoreceptor comprises a mucomodulator.

In certain embodiments the mechanoreceptor stimulator is in a delayedform for co-synchronization with the CNS active agent. For example, inone formulation, the CNS active agent has a time to maximumconcentration (Tmax) and the mechanoreceptor stimulator has a Tmax, thedelay in the release of mechanoreceptor stimulator is equal to the Tmaxof the CNS active agent minus the Tmax of the mechanoreceptor stimulatorplus about 5 to about 30 minutes, more preferably plus about 10 to 20minutes.

In a preferred embodiment, at least one side-effect is reduced selectedfrom the group consisting of: sedation, somnolence, sleepnece, memoryimpairment, amnesia, impairment of cognitive and learning function,ataxia, impaired night sleep/day alertness, impaired memory, impairedconcentration, impaired appetite, drowsiness, hypotension, fatigue,kinetic disorders, catalepsy, movement disorders, bowel irritation andimpaired reaction. Preferably the side-effect that is reduced issedation.

In an exemplary embodiment, the invention is direct to a compositioncomprising a central nervous system (CNS) active agent and at least twovagal neuromodulators, wherein the CNS active agent has a time tomaximum concentration (Tmax) and the at least two vagal neuromodulatorseach have a Tmax, wherein the Tmax of the CNS active agent is greaterthan the Tmax of at least one vagal neuromodulator and the release of atleast one vagal neuromodulator is delayed, the delay being equal to theTmax of the CNS active agent minus the Tmax of the neuromodulator plusabout 5 to about 30 minutes. Preferably, in this embodiment the at leasttwo vagal neuromodulators comprise at least one mechanoreceptorstimulator and the mechanoreceptor stimulator is in a delayed releaseform. For example, the formulation of this embodiment may comprise GUAand PSE, wherein the GUA is released between about 10 and about 20minutes after the CNS active agent.

The invention is further directed to a method of reducing a side-effectof a CNS active agent. Preferably, the method comprises: administeringthe CNS active agent to a patient; and administering at least two vagalneuromodulators to the patient in an amount sufficient to reduce aside-effect of the CNS active agent. Particularly, at least oneneuromodulator may be administered or released at least about 5 minutesafter the CNS active agent is administered or released. In a specificembodiment, the neuromodulator is administered or released after the CNSactive agent is administered or released, preferably within 30 minutes.In this embodiment the CNS agent maybe in an amount that issubstantially the same as the conventionally accepted effective dosage,yet still have a reduction in at least one side-effect of the CNS. Theat least two vagal neuromodulators may also comprise at least onemechanoreceptor stimulator as stated above, wherein the at least twovagal neuromodulators are in an amount sufficient to reduce theside-effect associated with the CNS active agent. Specifically, therelease or the administration of the mechanoreceptor stimulator may bedelayed. In this embodiment, the delay in the administration or releaseof mechanoreceptor stimulator is typically equal to the Tmax of the CNSactive agent minus the Tmax of the mechanoreceptor stimulator plus about5 to about 30 minutes.

In an alternative embodiment, the invention is directed to a method forreducing dependency or toxicity of an addictive central nervous system(CNS) active agent. The method comprises: administering to a patientbetween about 5 to about 80 percent, more preferably less than about60%, and most preferably less than about 50% of the conventionallyaccepted effective dosage of the addictive CNS active agent for thedesired treatment. The method further comprises administering to thepatient at least two vagal neuromodulators in an amount sufficient toreduce the dosage of the addictive CNS active agent without reduction ofefficacy. Preferably the at least two vagal neuromodulators comprises amechanoreceptor stimulator and a chemoreceptor stimulator. Typically, inthis embodiment, the mechanoreceptor is released or administered afterthe CNS active agent. For example, the CNS active agent themechanoreceptor stimulator is administered or released at a time equalto the Tmax of the CNS active agent minus the Tmax of themechanoreceptor stimulator plus about 5 to about 30 minutes, morepreferably about 10 to about 20 minutes.

The invention is further directed to a pharmaceutical kit. The kitpreferably comprises a central nervous system (CNS) active agent; and atleast two vagal neuromodulators, wherein the vagal neuromodulators arein an amount sufficient to reduce a side-effect of the CNS active agentand at least one of the vagal neuromodulators is a mechanoreceptorstimulator. The vagal neuromodulators may be in separate dosage forms tobe administrated separately or together.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a dosage form presented as a fixed kit, wherein thekit allows for the simple administration of day time and night timedosage forms;

FIG. 2 illustrates another dosage form presented as a fixed kit, whereinthe kit allows for the simple administration of day time and night timedosage forms;

FIG. 3 illustrates yet another dosage form presented as a fixed kit,wherein the kit allows for the simple administration of day time andnight time dosage forms;

FIG. 4 illustrates a dosage form presented as a fixed kit, comprising asingle package with a double dual reservoir that does not require thedosage forms to be in contact with each other before opening by thepatient or caregiver;

FIG. 5 illustrates the study scheme used in Examples 7 and 9;medications consisted of 1 mg alprazolam “ALP” (Xanax), 1 mg LRZlorazepam “LRZ” (Activan), neuromodulors “NM”, and a placebo “PLZ”;subjects were monitored over the course of six hours;

FIG. 6 shows a bar graph and corresponding table indicating the timespent sleeping by subjects in Examples 7 (subjects 101-104; alprazolam“ALP”) and 9 (subjects 105-108; lorazepam “LRZ”); and

FIG. 7 illustrates the study scheme used in Example 10; medicationsconsisted of active pharmaceutical ingredients “API” (alprazolam [Xanax]or lorazepam [Activan]), pseudoephedrine “NM1”, guaifenesin “NM2”, or aplacebo “PLAC”.

DETAILED DESCRIPTION OF THE INVENTION

The present invention comprises pharmaceutical compositions and methodsfor administering the pharmaceutical compositions by combining at leasttwo, preferably three, therapeutic agents, at least one of which is theCNS active agent. The other therapeutic agent comprises at least onevagal neuromodulator, which is a neuromodulator of the efferent orafferent vagal nerve. In general, the advantage of the pharmaceuticalcomposition of the present invention is that the disclosed combinationreduces a side-effect associated with the CNS active agent and/or thatthe therapeutically effective amount of CNS active agent used inconjunction with the combination of neuromodulators of present inventionis 1.2-100 folds lower than the conventionally accepted effective dosageof same CNS active agent when used alone.

The pharmaceutical composition of the present invention will now bedescribed in more detail. Broadly described, “CNS active agent” refersto any active pharmaceutical/therapeutic ingredient/compound/agent (drugsubstance or product) that induces sedation-related effects.“Sedation-related effects” are side effects of the compound (whentherapeutic effect is tranquilizing, anexielytic, analgetic,spasmolytic, neuroprotective, etc.). Sometimes, a CNS drug with sedativeactivity may be used in the treatment of sleeping disorders, such asinsomnia (benzodiazepines and non-benzodiazepines such as zolpidem,zaleplon, zopiclone, eszopiclone, etc.), hypnosis(Rohypnol-flunitrazepam, opiods, etc.), and narcolepsy (Xyrem-sodiumoxybate-GHB). However, these same drugs are often used therapeuticallyto treat other conditions, in which case sedation is a side effect. Forexample, ORG 50081 esmirtazapine, the (S)-(+)-enantiomer of mirtazapine,developed by Schering-Plough, has been used in the treatment of insomniaand menopausal symptoms (i.e. hot flashes). Expansion in the use ofother CNS drugs is possible through a reduction in sedation-relatedeffects. For example, in the areas of:

-   -   Anti-pain: opiates, flunarizine, metoprolol, amitriptyline, and        methotrimeprazine (Nozinan®)    -   Muscle relaxants to treat pain (MRs): robaxin, baclofen,        flexeril (cyclobenzaprine), soma (carisoprodol), chlorzoxazone,        benzodiazepines, methocarbamol, metaxalone, and orphenadrine    -   Anti-convulsants: carbamazepine, benzodiazepines, gabapentin        (Neurontin®), barbiturates (phenobarbital), primidone,        hydantoins, sodium valproate, tiagabine, levetiracetam, and        lamotrigine    -   Anti-Psychotics: (anti-schizophrenia) clozapine, olanzapine,        quetiapine (marketed by AstraZeneca as Seroquel and by Orion        Pharma as Ketipinor), ziprasidone, and aripiprazole;        (anti-bipolar) depakote, tegretol, and trileptal; and        (anti-mania) asenapine    -   Anti-Depressants: mirtazapine (Remeron, Avanza, Zispin, Reflex)        elavil (amitriptyline), tofranil (imipramine), norpramin        (desipramine), pamelor (nortripyline), sinequan (doxepin),        anafranil, lomipramine, trazodone, and nefazadone    -   Sedation-inducing drugs used in Neurodegenerative diseases:        (anti-parkinsonian) apomorphine, bromocriptine, cabergoline,        lisuride, pergolide, ropinirole, pramipexole, benzatropine, and        biperiden; anti-Alzheimer

The CNS active agent of the present invention may be described accordingto various classifications and categories, including antidepressants,such as norephrine-reuptake inhibitors, serotonin-reuptake inhibitors,monoamine-oxidase inhibitors, serotonin- and noradrenalin-reuptakeinhibitors, corticaotrop-releasing-factor antagonists, α-adrenoreceptorantagonists, 5-HT_(1A) receptor antagonists and partial agonists,N-methyl-D-aspartate receptor antagonists, and GABA analogues,intermediates and modulators, and NK-1-receptor antagonists. Othercategories of CNS agents include benzodiazepines, barbiturates, opioidsand other addictive drugs, analgesics, antipsychotics andantidepressants, muscle relaxants and nonbenzodiazepines,antispasmolytics, antihistamines and drugs for treatment ofneurodegenerative diseases. It should be recognized that some CNS activeagents may fall into more than one category. The CNS active agent of thepresent invention may contain one or more chiral centers and/or doublebonds and, therefore, includes all stereoisomers, such as double-bondisomers (i.e., geometric isomers), enantiomers, and diastereomers. Inaddition, the CNS active agents discussed herein also include allpharmaceutically acceptable salts, complexes (e.g., hydrates, solvates,and clathrates) and prodrugs thereof. In a preferable embodiment, suchcompounds are GABA agonists (i.e. benzodiazepine receptor agonists), orany other compound that performs CNS-inhibiting neuronal activity as thedesired therapeutic mechanism (somnolence drugs, anesthetics,hypnotics). The CNS active agents of the present invention will now bedescribed in greater detail.

“Antidepressant” means any compound or composition that, when testedaccording to standard in vivo or in vitro assays, displaysreceptor-binding properties or other mechanistic properties associatedwith the clinically approved antidepressants or any compound orcomposition known or to be discovered that has demonstrated clinicalefficacy in treating depression in mammals including those compounds andcompositions that have been approved for treating depression in humans.Classes of antidepressants include norepinephrine-reuptake inhibitors(NRIs), selective-serotonin-reuptake inhibitors (SSRIs),monoamine-oxidase inhibitors (MAOIs),serotonin-and-noradrenaline-reuptake inhibitors (SNRIs);corticotropin-releasing factor (CRF) antagonists, α-adrenoreceptorantagonists; NK1-receptor antagonists, 5-HT_(1A)-receptor agonist,antagonists, and partial agonists, atypical antidepressants, and otherantidepressants.

Starting with norepinephrine-reuptake inhibitors, each of these classesof antidepressants will now be described in greater detail.“Norepinephrine-reuptake inhibitors” are compounds that whenadministered systemically in a mammal, inhibit norepinephrine-reuptakeor that display receptor-binding properties or other mechanisticproperties associated with norepinephrine-reuptake inhibitors whentested according to standard in vivo or in vitro assays, such as aredescribed in Wong et al., 61 J. Pharm. Exp. Therap. 222 (1982); P.Skolnick et al., 86 BR. J. Pharmacology 637-644 (1985), which areincorporated herein by reference. Norepinephrine-reuptake inhibitorscomprise amitriptyline, desmethylamitriptyline, clomipramine, doxepin,imipramine, imipramine-oxide, trimipramine, adinazolam,amiltriptylinoxide, amoxapine, desipramine, maprotiline, nortriptyline,protriptyline, amineptine, butriptyline, demexiptiline, dibenzepin,dimetacrine, dothiepin, fluacizine, iprindole, lofepramine, melitracen,metapramine, norclolipramine, noxiptilin, opipramol, perlapine,pizotyline, propizepine, quinupramine, reboxetine, and tianeptine. Othernorepinephrine-reuptake inhibitors include the tricyclic compoundsencompassed by the generic formula disclosed in U.S. Pat. No. 6,211,171,which is incorporated herein by reference.

Serotonin-reuptake inhibitors will now be described. “Serotonin reuptakeinhibitors” are compounds that inhibit reuptake of serotonin whensystemically administered in mammals or that display receptor-bindingproperties or other mechanistic properties associated withserotonin-reuptake inhibitors when tested according to standard in vivoor in vitro assays such as are described in Wong, et al., 8Neuropsychopharmacology 337 (1993); U.S. Pat. No. 6,225,324; and U.S.Pat. No. 5,648,396, which are incorporated herein by reference. Examplesof serotonin-reuptake inhibitors comprise binedaline, m-chloropiperzine,citalopram, duloxetine, etoperidone, escitalopram, femoxetine,fluoxetine, fluvoxamine, indalpine, indeloxazine, milnacipran,nefazodone, oxaflazone, paroxetine, prolintane, ritanserin, sertraline,tandospirone, venlafaxine and zimeldine.

Turning now to monoamine-oxidase inhibitors (MAOIs), MAOIs are compoundsthat when administered systemically in a mammal, act asmonoamine-oxidase inhibitors or that inhibit monoamine oxidase whentested according to standard in vivo or in vitro assays, such as may beadapted from the monoamine-oxidase inhibitory assay described in 12Biochem. Pharmacol. 1439 (1963) and Kinemuchi et al., 35 J. Neurochem.109 (1980); U.S. Pat. No. 6,096,771, which are incorporated byreference. Examples of non-selective MAOlIs comprise amiflamine,vanoxerine boxeprazine, AGN 2253 (Nicholas Kiwi), iproniazid,isocarboxazid, M-3-PPC (Draxis), nialamid, phenelzine, pargyline, andtranylcypromine and pharmaceutically acceptable salts thereof. Examplesof selective MAOIs comprise clorgyline, cimoxatone, befloxatone,brofaromine, bazinaprine, BW-616U (Burroughs Wellcome), BW-1370U87(Burroughs Wellcome), CS-722 (RS-722) (Sankyo), E-2011 (Eisai), harmine,harmaline, moclobemide, PharmaProjects 3975 (Hoechst), RO 41-1049(Roche), RS-8359 (Sankyo), T-794 (Tanabe Seiyaku), toloxatone, K-Y 1349(Kalir and Youdim), LY-51641 (Lilly), LY-121768 (Lilly), M&B 9303 (May &Baker), MDL 72394 (Marion Merrell), MDL 72392 (Marion Merrell),sercloremine, and MO 1671. Other MAOIs comprise budipine, caroxazone,D-1711 (Biocodex), fezolamine, FLA-334 (RAN-1 13) (Astra), FLA-289(FLA-299, FLA-365, FLA-384, FLA-463, FLA-727) (Astra), K-1 1566(Pharmacia Upjohn, Farmitalia), K-1 1829 (Pharmacia Upjohn, Farmitalia),metralindole, MPCPAM (Yissum), PharmaProjects 227 (Syntex/Roche),PharmaProjects 2806 (Fournier), PharmaProjects 1122, PharmaProjects 3311(Roche), PharmaProjects 4433 (Roche), RS-2232 (Sankyo), and UP-614-04(Bristol-Myers). Still other MAOIs comprise bifemelane, brofaromide,hypericin, iproclozide, medifoxamine, nialamide, octamoxin,phenoxypropaazine, pivalyl benzhydrazine, prodipine, selegiline, andbenmoxine.

CNS active agents of the present invention also include “serotonin- andnoradrenalin-reuptake inhibitors” (SNRIs). SNRIs are compounds that,when administered systemically in a mammal, act as serotonin- andnoradrenaline-reuptake inhibitors or that display receptor-bindingproperties or other mechanistic properties associated with serotonin-and noradrenalin-reuptake inhibitors when tested according to standardin vivo or in vitro assays, such as are described in U.S. Pat. No.6,172,097, which is incorporated by reference. Examples of SNRIscomprise mirtazapine, and venlafaxine.

Corticotropin-releasing-factor antagonists (CRF antagonists) are alsoCNS active agents. CRF antagonists are compounds that, when administeredsystemically in a mammal, act as corticotropin-releasing factorantagonists or that display receptor-binding properties or othermechanistic properties associated with CRF antagonists, when testedaccording to standard in vivo or in vitro assays, such as are describedin U.S. Pat. No. 6,218,391, which is incorporated by reference. Examplesof CRF antagonists comprise those described in U.S. Pat. Nos. 6,191,131;6,174,192; 6,133,282; PCT Patent Application Publication Nos. WO94/13643, WO 94/13644, WO 94/13661, WO 94/13676 and WO 94/13677, whichare incorporated by reference.

α-Adrenoreceptor antagonists will now be described in greater detail.α-Adrenoreceptor antagonists are compounds that, when administeredsystemically in a mammal, act as α-adrenoreceptor antagonists or thatact as α-adrenoreceptor antagonists when tested according to standard invivo or in vitro assays, such as are described in U.S. Pat. No.6,150,389, which is incorporated by reference. Examples ofα-adrenoreceptor antagonists comprise phentolamine and those describedin U.S. Pat. No. 6,150,389, which is incorporated by reference.

5-HT_(1A)-receptor agonist, antagonists, and partial agonists (5-HT_(1A)agents) will now be described. 5-HT_(1A) agents are compounds that whenadministered systemically in a mammal, act as 5-HT_(1A)-receptoragonist, antagonists, and partial agonists or that act as5-HT_(1A)-receptor agonist, antagonists, and partial agonists, whentested according to standard in vivo or in vitro assays, such as mightbe adapted from the 5-HT_(1A) receptor binding assays described in U.S.Pat. Nos. 6,255,302 and 6,239,194, are expressly incorporated byreference. Examples of 5-HT_(1A) agents comprise buspirone, flesinoxan,gepirone, and ipsapirone, and those disclosed in U.S. Pat. Nos.6,255,302; 6,245,781 and 6,242,448. An example of a compound with5-HT_(1A) receptor antagonist/partial agonist activity is pindolol.

N-methyl-D-aspartate receptor antagonists (NMDAs) represent another CNSactive agent. The NMDA receptor is a cell-surface protein complex in theclass of ionotropic-glutamate receptors, with a structure comprising aligand-gated/voltage-sensitive ion channel. The NMDA receptor isbelieved to contain at least five distinct binding (activation) sites: aglycine-binding site, a glutamate-binding site (NMDA-binding site); aphencyclidine (PCP)-binding site, a polyamine-binding site, and azinc-binding site. In general, a receptor antagonist is a molecule thatblocks or reduces the ability of an agonist to activate the receptor.NMDA-receptor antagonist is any compound or composition that, whencontacted with the NMDA receptor in vivo or in vitro, inhibits the flowof ions through the NMDA-receptor ion channel. NMDA-receptor antagonistsuitable for use in the invention can be identified by testingNMDA-receptor antagonist for local-anesthetic and peripheralantinociceptive properties according to standard pain models. See e.g.,J. Sawynok et al., 82 Pain 149 (1999); J. Sawynok et al., 80 Pain 45(1999).

In one embodiment, the NMDA-receptor antagonist is a non-competitiveNMDA-receptor antagonist, preferably, ketamine and/or ketaminehydrochloride. In addition, NMDA-receptor antagonist further comprisesany compound or composition that antagonizes the NMDA receptor bybinding at the glycine site. These NMDA-receptor antagonists can beidentified by standard in vitro and in vivo assays, such as aredescribed in U.S. Pat. No. 6,251,903; U.S. Pat. No. 6,191,165; Grimwoodet al. 4 Molecular Pharmacology 923 (1992); Yoneda et al 62 J.Neurochem. 102 (1994); and Mayer et al. J. Neurophysiol. 645 (1988),which are incorporated by reference. Glycine-site NMDA-receptorantagonists comprise glycinamide, threonine, D-serine, felbamate,5,7-dichlorokynurenic acid, and 3-amino-1-hydroxy-2-pyrrolidone(HA-966), diethylenetriamine, 1,10-diaminodecane, 1,12-diaminododecane,and ifenprodil and those described in U.S. Pat. Nos. 6,251,903;5,914,403; 5,863,916; 5,783,700; and U.S. Pat. No. 5,708,168, which areincorporated by reference.

In yet another embodiment, the NMDA-receptor antagonist comprises anycompound or composition that antagonizes the NMDA receptor by binding atthe glutamate site, also known as “competitive NMDA-receptorantagonists.” Competitive NMDA receptor antagonists comprise3-(2-carboxypiperazin-4-yl)propyl-1-phosphonic acid (CPP);3-[(R)-2-carboxypiperzin-4-yl)-prop-2-enyl-1-phosphonic acid (CPP-ene);1-(cis-2-carboxypiperidine-4-yl)methyl-1-phosphonic acid (CGS 19755),D-2-Amino-5-phosphonopentanoic acid (AP5); 2-amino-phosphonoheptanoate(AP7); D,L-(E)-2-amino-4-methyl-5-phosphono-3-pentenoic acidcarboxyethyl ester (CGP39551); 2-amino-4-methyl-5-phosphono-pent-3-enoicacid (CGP 40116); (4-phosphono-but-2-enylamino)-acetic acid (PD 132477);2-amino-4-oxo-5-phosphono-pentanoic acid (MDL 100,453);3-((phosphonylmethyl)-sulfinyl)-D,L-alanine;amino-(4-phosphonomethyl-phenyl)-acetic acid (PD 129635);2-amino-3-(5-chloro-1phosphonomethyl-1H-benzoimidazol-2-yl)-propionicacid; 2-amino-3-(3-phosphonomethyl-quinoxalin-2-yl)-propionic acid;2-amino-3-(5-phosphonomethyl-biphenyl-3-yl)-propionic acid (SDZ EAB515); 2-amino-3-&lsqb;2-(2-phosphono-ethyl)-cyclohexyl&rsqb;-propionicacid (NPC 17742); 4-(3-phosphono-propyl)-piperazine-2-carboxylic acid(D-CPP); 4-(3-phosphono-allyl)-piperazine-2-carboxylic acid (D-CPP-ene);4-phosphonomethyl-piperidine-2-carboxylic acid (CGS 19755);3-(2-phosphono-acetyl)-piperidine-2-carboxylic acid (MDL 100,925);5-phosphono-1,2,3,4-tetrahydro-isoquinoline-3-carboxylic acid (SC48981);5-(2-phosphono-ethyl)-1,2,3,4-tetrahydro-isoquinoline-3-carboxylic acid(PD 145950); 6phosphonomethyl-decahydro-isoquinoline-3-carboxylic acid(LY 274614); 4-(1H-tetrazol-Sylmethyl)-piperidine-2-carboxylic acid (LY233053 and 235723);6-(1H-Tetrazol-5-ylmethyl)-decahydro-isoquinoline-3-carboxylic acid (LY233536). References that disclose other competitive NMDA-receptorantagonists as well as assays for identifying competitive NMDA-receptorantagonists include Jia-He Li, et al., 38 J. Med. Chem. 1955 (1995);Steinberg et al, 133 Neurosci. Lett. 225 (1991); Meldrum et al., 11Trends Pharmacol. Sci., 379 (1990); Willetts et al., 11 TrendsPharmacol. Sci. 423 (1990); Faden et al., 13 Trends Pharmacol. Sci. 29(1992); Rogawski 14 Trends Pharmacol. Sci. 325 (1993); Albers et al, 15Clinical Neuropharm. 509 (1992); Wolfe et al., 13 Am. J. Emerg. Med.,174 (1995); and Bigge, 45 Biochem. Pharmacol. 1547 (1993), which areincorporated by reference.

Still another NMDA receptor antagonist comprises any compound orcomposition that antagonizes the NMDA receptor by binding at the PCPbinding site, also known as “non-competitive NMDA-receptor antagonists.”Non-competitive NMDA-receptor antagonists can be identified usingroutine assays, such as those described in U.S. Pat. Nos. 6,251,948;5,985,586; and 6,025,369; Jacobson et al., 110 J. Pharmacol. Exp. Ther.243 (1987); and Thurkaufet al., 31 J. Med. Chem. 2257 (1988), which areincorporated by reference. Examples of non-competitive NMDA-receptorantagonists that bind at the PCP site comprise ketamine, phencyclidine,dextromethorphan, dextrorphan, dexoxadrol, dizocilpine (MK-801),remacemide, thienylcyclohexylpiperidine (TCP), N-allylnormetazocine (SKF10,047), cyclazocine, etoxadrol,(1,2,3,4,9,9a-hexahydro-fluoren-4a-yl)-methyl-amine (PD 137889);(1,3,4,9,10,10a-hexahydro-2H-phenanthren-4a-yl)-methyl-amine (PD138289); PD 138558, tiletamine, kynurenic acid, 7-chloro-kynurenic acid,and memantine; and quinoxalinediones, such as6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and6,7-dinitro-quinoxaline-2,3-dione (DNQX).

In yet another embodiment, the NMDA-receptor antagonist comprisescompounds that block the NMDA receptor at the polyamine binding site,the zinc-binding site, and other NMDA-receptor antagonists that areeither not classified according to a particular binding site or thatblock the NMDA receptor by another mechanism. Examples of NMDA-receptorantagonists that bind at the polyamine site comprise spermine,spermidine, putrescine, and arcaine. Assays useful to identifyNMDA-receptor antagonists that act at the zinc or polyamine binding siteare disclosed in U.S. Pat. No. 5,834,465, which is incorporated byreference. Other NMDA-receptor antagonists comprise amantadine,eliprodil, iamotrigine, riluzole, aptiganel, flupirtine, celfotel, andlevemopamil.

The NMDA receptor also comprises pyroloquinolin quinone,cis-4-(phosphonomethyl)-2-piperidine carboxylic acid, MK801, memantine,and D-methadone.

The amount of NMDA-receptor antagonist in compositions of the inventionwill vary according to the type and identity of the NMDA-receptorantagonist, the concentration and identity of the antidepressant, andthe painful indiction treated. Dosages and concentrations for aparticular NMDA-receptor antagonist can be optimized according toroutine experiments using well-known pain models, for example, thosedescribed in J. Sawynok et al., 82 Pain 149 (1999) and J. Sawynok etal., 80 Pain 45 (1999). In general, the amount of NMDA-receptorantagonist in the pharmaceutical composition of the present inventionranges from about 0.1 percent to about 5 percent of the total weight ofthe composition, preferably, from about 0.3 percent to about 0.5 percentof the total weight of the composition. When combined with theneuromodulators of the present invention, the therapeutically effectiveamounts of NMDA receptor antagonist are approximately 1.2-100 foldslower than conventionally accepted effective dosage when theNMDA-receptor antagonist is used alone.

Turning now to a different category, GABA analogues, intermediates andmodulators will now be described. Gamma vinyl GABA (GVG) is a selectiveand irreversible inhibitor of GABA-transaminase (GABA-T) known topotentiate GABAergic inhibition. It is also known that GVG alterscocaine's biochemical effects by causing a dose-dependent and prolongedelevation of extracellular endogenous brain GABA levels. Anotherselective GABA modulator is zolpidom.

Another CNS active agent is g-Hydroxybutyric acid (GHB). GHB is alsoknown as sodium oxybate, sodium oxybutyrate, and others. GHB has beenused for intravenous induction of anesthesia, treatment of alcoholdependence and opiate withdrawal. GHB is a schedule I controlledsubstance in the U.S. The drug is rapidly absorbed orally with an onsetof action within 15 minutes. At lower doses of 25 mg/kg, the T_(max) ofGHB is approximately 30 minutes. After higher doses of 50 mg/kg, theT_(max) occurs around 45 minutes. Oral ingestion of GHB 75-100 mg/kg inhumans results in peak blood levels of approximately 90-100 μg/ml at 1-2hours after ingestion. GHB at 50 mg/kg/day has been given orally totreat the symptoms of acute alcohol withdrawal and to facilitate bothshort- and long-term abstinence from alcohol. It also was given to treatopiate withdrawal, often in higher dosages of 50-300 mg/kg/day.

CNS active agents also include NK1-receptor antagonists, which arecompounds that when administered systemically in a mammal, act asNK1-receptor antagonists (Neurokinn I substance P receptor antagonists)or that acts as NK1-receptor antagonists, when tested according tostandard in vivo or in vitro assays, such as may be adapted from theNK1-receptor-binding assay described in U.S. Pat. No. 6,117,855, whichis incorporated by reference. Examples of NK1-receptor antagonistscomprise those described in PCT Patent Application Publication Nos. WO95/16679, WO 95/18124, WO 95/23798, and European Patent SpecificationNo. 0 577 394.

Antidepressants comprise tricyclic antidepressants, such asamitryptyline, clomipramine, desipramine, dothiepin, doxepin,imipramine, nortriptyline, opipramol, protriptyline and trimipramine;tetracyclic antidepressants, such as mianserin; MOAIs such asisocarboxazid, phenelizine, tranylcypromine and moclobemide; andselective serotonin re-uptake inhibitors such as fluoxetine, paroxetine,citalopram, fluvoxamine and sertraline. In an embodiment of the presentinvention, preferably, the antidepressant is a norepinephrine-reuptakeinhibitor, a tricyclic antidepressant, amitriptyline, or, morepreferably, amitriptyline hydrochloride.

CNS active agents also include atypical antidepressants, such asbupropion, dimethazan, fencamine, fenpentadiol, levophacetoperance,metralindone, mianserin, cotinine, rolicyprine, rolipram, nefopam,lithium, trazodone, viloxazine, and sibutramine and pharmaceuticallyacceptable salts thereof.

Antidepressants also include selective serotonin reuptake inhibitors(SSRIs) and tricyclic antidepressants (tricyclics). Tricyclics includeamitriptyline (Elavil), desipramine (Norpramin), imipramine (Tofranil)and nortriptyline (Aventyl, Pamelor). Other antidepressants havemechanisms than are markedly different from SSRIs and tricylics. Commonantidepressants are venlafaxine (Effexor), nefazadone (Serzone),bupropion (Wellbutrin), mirtazapine (Remeron) and trazodone (Desyrel).Less commonly used are the monomine oxidase inhibitors (MAOIs), such asphenelzine (Nardil) and tranylcypromine (Parnate). Mirtazapine may beused in combination with SSRIs to boost antidepressive effect, improvesleep and avoid sexual side-effects. The conventionally acceptedeffective dose is 15-45 mg/day.

Specifically, mirtazapine is a tetracyclic antidepressant used primarilyin the treatment of depression. It is also sometimes used as a hypnotic,antiemetic, and appetite stimulant, and for the treatment of anxiety.Along with its close analogues mianserin and setiptiline, mirtazapine isone of the few noradrenergic and specific serotonergic antidepressants.Potential non-sedating applications of mirtazapine include: monotherapyof panic/generalized Anxiety disorder (GAD); adjunctive treatment to gapthe delayed onsent of SSRI anxiolytic activity in first diagnosed oracute stress patients; prevention of acute anxiety induced by localanesthesia-related surgery (dental, plastic, ophthalmology, etc.);on-demand use for prevention of panic attacks; improved and morereliable medication for GAD/panic disorder sufferers; and improvedpatient compliance due to reduced benzodiazepine (BDZ)-induced sideeffects, especially for GAD/panic disorder patients.

Further, CNS active agents comprise a wide variety of other drugs thatare thought to have antidepressant activity including, nomifensine,oxitriptan, oxypertine, thiazesim, adrafinil, benactyzine, butacetin,dioxadrol, febarbamate, hematoporphyrin, minaprine, piberaline,pyrisuccideanol, roxindole, rubidium chloride, sulpride, thozalinone,tofenacin, 1-tryptophan, alaproclate, amitriptyline-chlordiazepoxidecombination, atipamezole, azamianserin, bazinaprine, befuraline,binodaline, bipenamol, cericlamine, cianopramine, cimoxatone, clemeprol,clovoxamine, dazepinil, deanol, enefexine, estazolam, fezolamine,fluotracen, idazoxan, levoprotiline, litoxetine, montirelin, nebracetam,norfluoxetine, orotirelin, oxaflozane, pinazepam, pirlindone,setiptiline, sulbutiamine, sulpiride, teniloxazine, thymoliberin,tiflucarbine, tofisopam, tomoxetine, veralipride, viqualine, zimelidineand zometapine, and St. John's wort herb or hypericum perforatum, orextracts thereof.

The amount of antidepressant in compositions of the invention will varyaccording to the type and identity of the antidepressant, theconcentration and identity of the NMDA-receptor antagonist, and thepainful indiction treated. Dosages and concentrations for a particularantidepressants can be optimized according to routine experiments usingwell-known pain models, for example, those described in J. Sawynok etal., 82 Pain 149 (1999) and J. Sawynok et al., 80 Pain 45 (1999). Ingeneral, the amount of antidepressant in the pharmaceutical compositionof the present invention ranges from about 0.1 percent to about 10percent of the total weight of the pharmaceutical, preferably from about1 percent to about 5 percent of the total weight of the composition. Inanother embodiment, the amount of antidepressant ranges from about 0.5percent to about 8 percent.

Benzodiazepines of the present invention will now be described.Benzodiazepines are anxiolytic, anticonvulsant and sedative-hypnoticdrugs that can also act as antidepressants, muscle relaxants, amnestiesand antipsychotics. When administered orally, they become widelydistributed throughout the body, particularly in lipid-rich tissues suchas adipose cells and the brain. While high doses of benzopiaepines areoften required to obtain therapeutic benefits, such high dosages mayproduce severe sedative and hypnotic effects. Other problems associatedwith benzodiazepine use are physical withdrawal symptoms after abruptcessation of moderate to high doses and interaction with other CNSdepressants, especially alcohol. Long-term use can be problematic due tothe development of tolerance and physiological and psychologicaldependency.

Benzodiazepines are commonly divided into three groups: Short-actingcompounds which act for less than six hours and have few residualeffects if taken before bedtime such as the possibility of inducingrebound insomnia or wake-time anxiety. Intermediate-acting compoundshave an effect for 6-10 hours and may have mild residual effects.Long-acting compounds have strong sedative effects that persist.Accumulation of the compounds in the body may occur. The eliminationhalf-life may vary greatly between individuals, especially the elderly.

Various benzodiazepines and their respective trade names, half-lives,and primary uses, and conventionally accepted effective doses are listedin TABLE 1 below.

TABLE 1 Brief description of various benzodiazepines. Elimination CommonHalf-Life Conventionally Brand [active Primary Accepted Drug Name Namesmetabolite] Effects Effective Dose Alprazolam Xanax, 6-12 hoursanxiolytic 0.5 mg Xanor, Tafil, Alprox Bromazepam Lexotan, 10-20 hoursanxiolytic 5-6 mg Lexomil, Somalium, Bromam Chlordiazepoxide Librium,5-30 hours anxiolytic 25 mg Tropium, [36-200 hours] Risolid, KlopoxidCinolazepam Gerodorm 9 h sedative 40 mg Clobazam Frisium, 12-60 hoursanxiolytic, 5-20 mg Urbanol anticonvulsant Clonazepam Klonopin, 18-50hours anxiolytic, 0.5 mg Klonapin, anticonvulsant Rivotril ClorazepateTranxene [36-100 hours] anxiolytic, 15 mg anticonvulsant DiazepamValium, 20-100 hours anxiolytic, 10 mg Apzepam, [36-200] hypnotic,Stesolid, anticonvulsant, Apozepam, muscle relaxant Hexalid, ValaxonaEstazolam ProSom 10-24 h hypnotic 1-2 mg Flunitrazepam Rohypnol, 18-26hours hypnotic 1 mg Fluscand, [36-200 hours] Flunipam, Ronal FlurazepamDalmane [40-250 hours] hypnotic 15-30 mg Halazepam Paxipam [30-100hours] anxiolytic 20 mg Ketazolam Anxon 2 hours anxiolytic 15-30 mgLoprazolam Dormonoct 6-12 hours hypnotic 1-2 mg Lorazepam Ativan, 10-20hours anxiolytic 1 mg Temesta, Lorabenz Lormetazepam Noctamid, 10-12hours hypnotic 1-2 mg Pronoctan Medazepam Nobrium 36-200 hoursanxiolytic 10 mg Midazolam Dormicum, 3 hours hypnotic 5-15 mg Versed,(1.8-6 hours) Hypnovel Nitrazepam Mogadon, 15-38 hours hypnotic 10 mgApodorm, Pacisyn, Dumolid Nordazepam Madar, 50-120 hours anxiolytic 10mg Stilny Oxazepam Serax, 4-15 hours anxiolytic 20 mg Serenid, Serepax,Sobril, Oxascand, Alopam, Oxabenz, Oxapax Phenazepam Pinazepam Domar[40-100 hours] sedative 5-20 mg Prazepam Centrax [36-200 hours]anxiolytic 10-20 mg Quazepam Doral 25-100 hours hypnotic 20 mg TemazepamRestoril, 8-22 hours hypnotic 15 mg Normison, Euhypnos TetrazepamMylostan 3-26 hours Skeletal muscle 50 mg relaxant Triazolam Halcion, 2hours hypnotic 0.5 mg Rilamir

Benzodiazepines may also include brotizolam, demoxazepam, flumazenil,imidazenil and midazepam. Preferred benzodiazepines are alprazolam,diazepam, midazolam, clonazepam, lorazepam, and triazolam.Benzodiazepines, such as lorazepam, are preferably present in anessentially pure form, are poorly soluble, and are dispersible in atleast one liquid media. By “poorly soluble,” it is meant that thebenzodiazepines have a solubility in liquid dispersion media of lessthan ˜10 mg/mL, and preferably of less than ˜1 mg/mL. As noted above,the solubility of lorazepam in water is 0.08 mg/mL. Benzodiazepines canadditionally comprise one or more compounds useful in the condition tobe treated, such as antidepressants, steroids, antiemetics,antinauseants, spasmolytics, antipsychotics, opioids, carbidopa/levodopaor dopamine agonists, GABA modulators, anesthetics, and narcotics.

Another CNS active agent is zonisamide, which is a sulfonamideanticonylusant used as therapeutically to prevent migraines. Zonisamidehas also been demonstrated to be effective in some cases of neuropathicpain and has been studied in cases of obesity. Furthermore, zonisamideis approved for use as an adjunctive therapy in adults withpartial-onset seizures for adults; infantile spasm, mixed seizure typesof Lennox-Gastaut syndrome, myoclonic, and generalized tonic clonicseizure. The most common side effect of zonisamide is drowsiness.

Barbituates are yet another known CNS active agent. Barbituric acid andits derivatives are known to act mainly as sedatives, hypnotics andanesthetics. Certain derivatives, such as 5-ethyl-5-phenyl barbituricacid (Phenobarbital), for example, have an anticonvulsive effect and aretherefore employed in the treatment of epilepsy. However, like otherbarbituric acid derivatives, phenobarbital has also sedative andhypnotic effects that are disadvantageous in the treatment of epilepsy(TABLE 2).

TABLE 2 Psychiatric side-effects of anti-epileptics, including sedation.Drug Psychiatric side-effects Phenobarbital Depression, sedation, sleepdisturbances, psychosis, cognitive impairment, paradoxical agitation,delirium Primidone Sedation, mood lability, psychotic symptoms, deliriumBenzodiazepines Agitation, sedation, hallucinations, psychosis,cognitive impairment, delirium, withdrawal syndrome Hydantoins Similarto Phenobarbital Sodium valproate Sedation, hallucinations, depressivesymptoms, delirium Carbamazepine Depression, agitation, sedation,psychosis, cognitive impairment, delirium Tiagabine Psychosis (0.8% oftreated patients), depressive symptoms, sedation LevetiracetamIrritability, sedation and psychosis Gabapentin Sedation, agitation,fatigue Lamotrigine Sedation, depression, agitation, psychosis (0.3% oftreated patients)

Barbiturates in high concentrations may also prove neuroprotective;however, the dosages necessary to confer neuroprotection are toxic andcause lethargy, stupor, coma, or are lethal, making accepted dosages ofbarbiturates unsuitable for treatment of ischemia and otherneurodegenerative diseases. When used along with the neuromodulators ofthe present invention, lower therapeutically effective dosages may beachieved.

Opioids and other addictive drugs will now be discussed. As used herein,“opioid” means all agonists and antagonists of opioid receptors, such asmu (which can be denoted by mu or μ), kappa (which can be denoted bykappa or K), and delta (which can be denoted by delta or Δ) opioidreceptors and subtypes thereof. “Addictive drugs” are any substance thatis consumed by a mammal and causes addiction related behavior, cravingsfor the substance, rewarding/incentive effects, dependencycharacteristics, or any combination thereof. Addictive drugs comprisepsychostimulants, narcotic analgesics, alcohols and addictive alkaloids,such as nicotine, or combinations thereof. Examples of psychostimulantsinclude amphetamine, dextroamphetamine, methamphetamine, phenmetrazine,diethylpropion, methylphenidate, cocaine, phencyclidine, andmethylenedioxymethamphetamine. Examples of narcotic analgesics compriseopioids and include alfentanyl, alphaprodine, anileridine, bezitramide,codeine, diazepam, dihydrocodeine, diphenoxylate, ethylmorphine,fentanyl, heroin, hydrocodone, hydromorphone, isomethadone,levomethorphan, levorphanol, metazocine, methadone, metopon, morphine,opium extracts, opium fluid extracts, powdered opium, granulated opium,raw opium, tincture of opium, oxycodone, oxymorphone, pethidine,phenazocine, piminodine, racemethorphan, racemorphan, cocaine, heroinandthebaine. Other opioids are described in further detail below. Addictivedrugs also include hypnotics and sedatives, such as barbiturates,chlordiazepoxide, amylobarbitone, butobarbitone, pentobarbitone, choralhydrate, chlormethiazole, hydroxyzine and meprobamate, and alcohols,such as ethanol, methanol and isopropyl alcohol. Examples ofpsychostimulants include amphetamine, dextroamphetamine,methamphetamine, phenmetrazine, diethylpropion, methylphenidate,cocaine, phencyclidine, and methylenedioxymethamphetamine.

Addictive drugs may further comprise antianxiety agents such as thebenzodiazepines, alprazolam, bromazepam, chlordiazepoxide, clobazam,chlorazepate, diazepam, flunitrazepam, flurazepam, lorazepam,nitrazepam, oxazepam, temazepam and triazolam, and neuroleptic andantipsychotic drugs, such as the phenothiazines, chlorpromazine,fluphenazine, pericyazine, perphenazine, promazine, thiopropazate,thioridazine and trifluoperazine and the butyrophenones, droperidol andhaloperidol and the other antipsychotic drugs such as pimozide,thiothixene and lithium. CNS stimulants, such as caffeine, may also beincluded.

Cessation of addictive drugs brings with it numerous and unpleasantwithdrawal symptoms. For nicotine, withdrawal symptoms includeirritability, anxiety, restlessness, lack of concentration,lightheadedness, insomnia, tremors, increased hunger and weight gain,and of course, an intense craving for tobacco. Withdrawal symptoms fromthe cessation of opioid use include craving, anxiety, dysphoria,yawning, perspiration, lacrimation, rhinorrhoea, restless and brokensleep, irritability, dilated pupils, aching of bones, back and muscles,piloerection, hot and cold flashes, nausea, vomiting, diarrhea, weightloss, fever, increased blood pressure, pulse and respiratory rate,twitching of muscles and kicking movements of the lower extremities.Medical complications associated with injection of opioids include avariety of pathological changes in the CNS including degenerativechanges in globus pallidus, necrosis of spinal gray matter, transversemyelitis, amblyopia, plexitis, peripheral neuropathy, Parkinsoniansyndromes, intellectual impairment, personality changes, andpathological changes in muscles and peripheral nerves. Infections ofskin and systemic organs are also quite common including staphylococcalpneumonitis, tuberculosis, endocarditis, septicemia, viral hepatitis,human immunodeficiency virus (HIV), malaria, tetanus and osteomyelitis.Pharmaceutical agents used in treating opioid dependence, includingmethadone, naloxone, naltrexone, and clonidine, are not without theirdrawbacks, frequently causing their own set of side-effects. The presentinvention of combining the CNS active agent, in this embodiment,addictive drugs, with the neuromodulators of the present invention canbe used to reduce dosages of addictive drugs during the period oftherapy for withdrawal.

CNS active agents of the present invention may also comprise analgesics,including opioids and opiates, such as oral anileridine(Leritine®analogs of meperidine), Meperidine (Demerol®), Normeperidine,Morphine and congeners, codeine, Tylenol, anti-inflammatory agents,narcotics, antipyretics including the opioid analgesics-such asbuprenorphine, dextromoramide, dextropropoxyphene, fentanyl, alfentanil,sufentanil, hydromorphone, methadone, morphine, oxycodone, papavereturn,pentazocine, pethidine, phenoperidine, codeine and dihydrocodeine.Others include acetylsalicylic acid (aspirin), paracetamol, andphenazone. Analgesics have wide-ranging side-effects from mild tosevere, including sedation, psychic slowing, dysphoria, mood changes,psychosis, convulsions, constipation, nausea, mental clouding anddelirium. The conventionally accepted effective dosage of codeine rangesfrom doses of 15-30 mg, 1-3 times daily.

The CNS active agent of the present invention also includesantipsychotics. Conventional antipsychotics are antagonists of dopamine(02) receptors; atypical antipsychotics also have 02 antagonisticproperties, but with different binding kinetics, as well as, andactivity at other receptors, particularly 5-HT2A, 5-HT2c and 5-HT1 D.Examples of antipsychotics for use in the present invention areclozapine (Clozaril®), risperidone (Risperdal®), olanzapine (Zyprexa®),quetiapine (Seroquel®), ziprasidone (Geodon®), sertindole, amisuiprideand aripiprazole (Abilify®).

Structurally similar to the benzodiazepine family, olanzapine(2-methyl-4-(4-methyl-1-piperazinyl)-1OH-thieno[2,3-bJ ii ,5]benzo) isused to treat schizophrenia and biopolar mania, but has the significantside-effects of increased appetite and subsequent weight gain andsedation.

SEROQUEL® sustained release formulation (quetiapine fumarate sustainedrelease) and SEROQUEL® (original formulation quetiapine) are used totreat schizophrenia, bipolar disorder, major depressive disorder,dementia, and generalized anxiety disorder, in conventionally acceptedtherapeutic doses of 400-700 mg daily. While less likely to induceextra-pyramidal symptoms and long term tardive dyskinesia, one ofSEROQUEL®'s prominent side-effects is sedation. Other side-effectsinclude headache and dry mouth.

SEROQUEL XR is supplied for oral administration as 200 mg (yellow), 300mg (pale yellow), and 400 mg (white). Each 200 mg tablet contains 230 mgof quetiapine fumarate equivalent to 200 mg quetiapine. Each 300 mgtablet contains 345 mg of quetiapine fumarate equivalent to 300 mgquetiapine. Each 400 mg tablet contains 461 mg of quetiapine fumarateequivalent to 400 mg quetiapine. All tablets are capsule shaped and filmcoated. Inactive ingredients for SEROQUEL XR are lactose monohydrate,microcrystalline cellulose, sodium citrate, hypromellose, and magnesiumstearate. The film coating for all SEROQUEL XR tablets containhypromellose, polyethylene glycol 400 and titanium dioxide. In addition,yellow iron oxide (200 and 300 mg tablets) are included in the filmcoating of specific strengths.

Ganaxolone (3a-hydroxy-3b-methyl-5a-pregnan-20-one) is the 3b-methylatedsynthetic analog of the neurosteroid allopregnanolone (3a,5a-P), ametabolite of progesterone, and used to treat epilepsy in adults andchildren. Importantly, ganaxolone does not have significant classicalnuclear steroid hormone activity and, unlike 3a,5a-P, cannot beconverted to metabolites with such activity. As with 3a,5a-P, Ganaxolonepotentiation of the GABA_(A) receptor occurs at a site distinct from thebenzodiazepine site. Acute ganaxolone treatment is associated withreversible, dose-related sedation

Asenapine is described in U.S. Pat. No. 4,145,434. Clozapine,8-chloro-1I-(4-methyl-1-piperazinyl)-5H-dibenzo[be][1,4]diazepine, isused to treat schizophrenia. Risperidone,3-[2-[4-(6-fluoro-1,2-benzisoxazol-3-yl)piperidino]ethyl]-2-methyl-6,7,8,9-tetrahydro-4H-pyrido-[1,2-a]pyrimidin-4-one,is used to treat various psychotic diseases. Sertindole,1-[2-[4-[5-chloro-1-(4-fluorophenyl)-1H-indol-3-yl 1-1-10piperidinyl]ethyl]imidazolidin-2-one, is also used to treatschizophrenia. Quetiapine,5-[2-(4-dibenzo[bfI[1,4]thiazepin-1I-yl-1-piperazinyl)ethoxy]ethanol, isused to treat and its activity in assays which demonstrate utility inthe treatment of schizophrenia are described in U.S. Pat. No. 4,879,288.Quetiapine is typically administered as its (E)-2-butenedioate (2:1)salt. Aripiprazole,7-{4-[4-(2,3-dichlorophenyl)-1-piperazinyl]-butoxy}-3,4-dihydrocarbostyril or7-{4-[4-(2,3-dichlorophenyl)-1-piperazinyl]-butoxy}-3,4-dihydro-2(1H)-quinolinone,is an atypical antipsychotic agent used for the treatment ofschizophrenia. Amisulpride, a selective dopamine antagonist, is anatypical antipsychotic agent, higher doses of which block thepostsynaptic dopamine receptors resulting in an improvement inpsychoses. Amisulpride is not approved by the Food and DrugAdministration for use in the United States. Amisulpride (in 50 mgdoses) is marketed as a treatment for dysthymia in Italy (as Deniban).

Antidepressants may be used as analgesics at low doses to manage chronicback pain. Tricyclic antidepressants (TCAs), such as amitriptyline,nortriptyline, and imipramine, and selected tetracyclic agents arebelieved to control pain, due to the blockade of neurotransmitters,norepinephrine and serotonin. Side-effects of tricyclic antidepressants(TCAs) include anticholinergic side-effects (dry mouth, cardiacarrhythmias, orthostatic hypotension), sedation, and a lowered seizurethreshold.

Other analgesics will now be described. Methotrimeprazine (Nozinan®) isa phenothiazine with analgesic properties, but it also has prominentsedative, anticholinergic, and hypotensive effects, which may precludeits use in most long-term therapy. Carbamazepine is widely used forchronic neuropathic pain, such as trigeminal neuralgia, but has adverseeffects (mainly drowsiness, dizziness and gait disturbance) over twoweeks. Conventially accepted effected doses have been mostly 400-1000mg/day. Carbamazepine risks many interactions and toxicities ofparticular significance in the elderly (sedation, ataxia, hyponatremia,leukopenia). Its elimination half-life is about 12 hours. GabapentinGabapentin (Neurontin®), a well-known alpha-2-delta ligand,1-(aminomethyl)-cyclohexylacetic acid, is an antiepileptic agent that isalso approved to help alleviate neuropathic pain. Its mechanism ofaction is unknown. A second alpha-2-delta ligand, pregabalin,(S)-(+)-4˜amino-3˜(2-methylpropyl)butanoic acid, has been used foranticonvulsant and pain treatment. Additional alpha-2-delta ligands arealso known. Conventionally accepted effective Gabapentin dosing shouldbe initiated low and titrated 100 to 300 mg every three to five daysuntil pain relief is achieved or side-effects, such as dizziness orsomnolence, become intolerable.

Other suitable CNS active agents of the present invention also includemuscle relaxants (MRs) such as nonbenzodiazepines generally andbaclofen, diazepam, cyclobenzaprine hydrochloride, dantrolene,methocarbamol, orphenadrine and quinine.

Nonbenzodiazepines include a variety of drugs that can act at the brainstem or spinal cord level. Cyclobenzaprine is structurally related tothe tricycle antidepressant amitriptyline but is not clinically used asan antidepressant. Cyclobenzaprine relieves muscle spasms, but is noteffective for the treatment of muscle spasms due to CNS diseases, suchas cerebral palsy or spinal cord disease. Cyclobenzaprine possessesanticholinergic activity unlike that of carisoprodol, due to thestructural similarity to amitriptyline. A 5-mg dose has been found to beas effective as a 10-mg dose and has the advantage of less sedation.Cyclobenzaprine should be initiated with the lowest dose (5 mg) andtitrated up slowly. Elimination half-life is 1-3 days, and hence it canbe given as a single bedtime dose. Possible side-effects includedrowsiness, dizziness, and anticholinergic effects.

Carisoprodol and metaxalone have moderate antispasmodic effects and aremildly sedative. Similar to Carisoprodol, most of Metaxalone'sbeneficial effects are thought to be due to its sedative properties.Principal advantages over other commonly used MRs include lack of abuse,limited accumulation due to relatively short elimination half-life, andrelatively low degree of sedation. A disadvantage of metaxalone may beits duration of four to six hours. The conventionally accepted effectivedose of metaxalone is 400 to 800 mg, three to four times daily. In somecases, metaxalone should be avoided in elderly patients, due to itsanticholinergic and sedative side-effects.

Methocarbamol (Robaxin®) including various formulations combined withacetaminophen, ASA, and codeine (e.g. Robaxacet-8®, Robaxisal-C®) haslong been available to treat non-neuropathic pain. It also has asedative effect.

The use of MRs for lower back pain (LBP) remains controversional, mainlybecause of their side-effects. In addition to sedation, potentialadverse effects include drowsiness, headache, blurred vision, nausea,and vomiting, potential to abuse. Muscle relaxants and theirconventionally accepted effective dosages are listed in TABLE 3 below.

TABLE 3 Conventionally accepted dosaged of various muscle relaxants.Muscle Relaxants Usual Dosage Range Carisoprodol 350 mg, 4 times dailyChlorzoxazone 250-500 mg, 3-4 times daily Cyclobenzaprine 5-10 mg, 3-4times daily Diazepam 2-10 mg, 3-4 times daily Methocarbamol 4,000-4,500mg/day in divided doses Metaxalone 400-800 mg, 3-4 times daily

In addition, Baclofen and tizanidine are indicated for spasticity andmuscle spasms associated with multiple sclerosis and spinal cord trauma.All agents in this drug class appear to have a similar onset of actionbut vary in their elimination half-lives, duration of activity,pharmacokinetics, and pharmacodynamics.

CNS active agents also include sedating antihistamines. Diphenhydramineand doxylamine are oral, sedating antihistamines that may be used forinsomnia and nocturnal pain.

Other CNS active agents also comprise zaleplon, zolpidem, eszopicloneand trazodone, which induce sleep.

Drugs for treatment of Neurodegenerative diseases will now be described.Many of the drugs used to treat agitation accompanying neurodegenerativediseases, such as anti-Parkinsonian-PD and Anti-Alzheimer disease-ADdrugs like Arricept, Exelon, Memantine, and tacrine illicitdoes-dependent, psychiatric side-effects, specifically sedation,particularly in the elderly (TABLE 4).

TABLE 4 Psychiatric side-effects of antiparkinsonian drugs, includingsedation. Drug(s) Psychiatric side-effects Apomorphine, bromocriptine,Sedation, psychomotor agitation, anxiety, cabergoline, lisuride,akathisia, sleep disturbance, pergolide, ropinirole, hallucinations,psychosis, cognitive pramipexole impairment, delirium BenzatropineSedation, anxiety, psychosis, delirium, visual hallucinations, potentialfor misuse Biperiden Sedation, anxiety, psychosis, delirium, visualhallucinations

Included in this category of CNS active agents are: Antiparkinson agentssuch as amantadine, benserazide, carbidopa, levodopa, benztropine,biperiden, benzhexyl, procyclidine and dopamine-2 agonists such asS(−)-2-(N-propyl-N-2-thienylethylamino)-5-hydroxytetralin (N-0923);anticonvulsants such as phenyloin, valproic acid, primidone,phenobarbitone, methylphenobarbitone and carbamazepine, ethosuximide,methsuximide, phensuximide, sulthiame and clonazepam.

Antiemetics, antinauseants such as the phenothiazines, prochloperazine,thiethylperazine and 5HT-3 receptor antagonists such as ondansetron andgranisetron and others such as dimenhydrinate, diphenhydramine,metoclopramide, domperidone, hyoscine, hyoscine hydrobromide, hyoscinehydrochloride, clebopride and brompride.

CNS agents generally are prescribed according to their conventionallyaccepted effective dosage. Conventionally accepted effective dosages forsome CNS agents are listed below:

Antipsychotics:

-   -   Clozapine: Adults: Initial: 12.5 mg qd-bid. Titrate: Increase by        25-50 mg/day, up to 300-450 mg/day by end of 2nd week, then        increase weekly or bi-weekly by up to 100 mg. Usual: 100-900        mg/day given tid. Max: 900 mg/day    -   Olanzapine: Usual Dose—Oral olanzapine should be administered on        a once-a-day schedule without regard to meals, generally        beginning with 5 to 10 mg initially, with a target dose of 10        mg/day within several days.    -   Quetiapine (Seroquel): Bipolar Disorder: Depressive Episodes:        Give once daily hs. Day 1: 50 mg/day. Day 2: 100 mg/day. Day 3:        200 mg/day. Day 4: 300 mg/day. Bipolar Mania:        Monotherapy/Adjunctive: Give bid. Initial: 100 mg/day on Day 1.        Titrate: Increase to 400 mg/day on Day 4 in increments of up to        100 mg/day in bid divided doses. Adjust doses up to 800 mg/day        by Day 6 in increments ≦200 mg/day. Max: 800 mg/day. Maintenance        for Bipolar I Disorder: Give bid. 400-800 mg/day. Schizophrenia:        Initial: 25 mg bid. Titrate: Increase by 25-50 mg bid-tid on the        2nd and 3rd day to 300-400 mg/day given bid-tid by the 4th day.        Adjust doses by 25-50 mg bid at intervals of at least 2 days.        Maint: Lowest effective dose. Max: 800 mg/day.    -   Ziprasidone (Geodon): Efficacy in schizophrenia was demonstrated        in a dose range of 20 to 100 mg BID in short-term    -   Aripiprazole: The recommended starting and target dose for        ABILIFY is 10 mg/day or 15 mg/day administered on a once-a-day        schedule without regard to meals. ABILIFY has been        systematically evaluated and shown to be effective in a dose        range of 10 mg/day to 30 mg/day, when administered as the tablet        formulation    -   Depakote: Initial: 10-15 mg/kg/day. Titrate: Increase by 5-10        mg/kg/week. Max: 60 mg/kg/day.    -   Tegretol: Initial: (Immediate- or Extended-Release Tabs) 200 mg        bid or (Sus) 100 mg qid, itrate: (Immediate-Release Tabs/Sus)        Increase weekly by 200 mg/day given tid-qid. (Extended-Release        Tabs) Increase weekly by 200 mg/day given bid. Maint: 800-1200        mg/day. Max: 1200 mg/day.    -   Trileptal-Monotherapy: Initial: 4-5 mg/kg bid. Titrate: Increase        by 5 mg/kg/day every 3rd day. Maint (mg/day): 20 kg: Initial:        600 mg. Max: 900 mg. 25-30 kg: Initial: 900 mg. Max: 1200 mg.        35-40 kg: Initial: 900 mg. Max: 1500 mg. 45 kg: Initial: 1200        mg. Max: 1500 mg. 50-55 kg: Initial: 1200 mg. Max: 1800 mg.        60-65 kg: Initial: 1200 mg. Max: 2100 mg. 70 kg: Initial: 1500        mg. Max: 2100 mg. Adjunct Therapy: Initial: 4-5 mg/kg bid. Max:        600 mg/day. Titrate: Increase over 2 weeks. Maint (mg/day):        20-29 kg: 900 mg. 29.1-39 kg: 1200 mg. >39 kg: 1800 mg.

Analgesics:

-   -   Amitriptyline-Initial: (Outpatient) 75 mg/day in divided doses        or 50-100 mg qhs. (Inpatient) 100 mg/day. Titrate: (Outpatient)        Increase by 25-50 mg qhs. (Inpatient) Increase to 200 mg/day.        Maint: 50-100 mg qhs. Max: (Outpatient) 150 mg/day. (Inpatient)        300 mg/day    -   Methotrimeprazine (Nozinan®): Minor conditions in which Nozinan        may be given in low doses as a tranquilizer, anxiolytic,        analgesic or sedative: begin treatment with 6 to 25 mg/day in 3        divided doses at mealtimes. Increase the dosage until the        optimum level has been reached. As a sedative, a single night        time dose of 10 to 25 mg is usually sufficient. Severe        conditions: Such as psychoses or intense pain in which Nozinan        is employed at higher doses: Begin treatment with 50 to 75        mg/day divided into 2 or 3 daily doses; increase the dosage        until the desired effect is obtained. In certain psychotics,        doses may reach 1 g or more/day. If it is necessary to start        therapy with higher doses, i.e., 100 to 200 mg/day, administer        the drug in divided daily doses and keep the patient in bed for        the first few days.

Muscle Relaxants (MRs):

-   -   Robaxin: Initial: (500 mg tab) 1500 mg qid for 2-3 days. Maint:        1000 mg qid. Initial: (750 mg tab) 1500 mg qid for 2-3 days.        Maint: 750 mg q4h or 1500 mg tid. Max: 6 g/d for 2-3 days; 8 g/d        if severe    -   Baclofen: Initial: 5 mg tid for 3 days. Titrate: May increase        dose by 5 mg tid every 3 days. Usual: 40-80 mg/day. Max: 80        mg/day (20 mg qid).    -   Flexeril (cyclobenzaprine): Usual: 5 mg tid. Titrate: May        increase to 10 mg tid    -   Soma (Carisoprodol): 250 mg to 350 mg three times a day and at        bedtime    -   Cyclobenzaprine: 15 mg qd. Titrate: May increase to 30 mg qd if        needed,    -   Metaxalone: one 800 mg tablet three to four times a day    -   Orphenadrine: 100 mg bid, in the am and pm

Neurodenenerative Diseases: Anti-Parkinsonian

-   -   Apomorphine: 2 mg SC; closely monitor BP. Titrate: Increase by 1        mg every few days; assess efficacy/tolerability. Max: 6 mg/day.    -   Bromocriptine: 25 mg bid. Titrate: if needed, increase by 2.5        mg/day every 2-4 weeks. Max: 100 mg/day.    -   Cabergoline: 0.25 mg twice weekly. Titrate: May increase by 0.25        mg twice weekly at 4 week intervals. Max: 1 mg twice weekly.    -   Ropinirole: The recommended starting dose for Parkinson's        disease is 0.25 mg 3 times daily; based on individual patient        response, dosage should then be titrated with weekly increments        as described in Table 5. After week 4, if necessary, daily        dosage may be increased by 1.5 mg/day on a weekly basis up to a        dose of 9 mg/day, and then by up to 3 mg/day weekly to a total        dose of 24 mg/day.    -   Benzatropine-Initial: 0.5-1 mg PO/IV/IM qhs. Titrate: May        increase every 5-6 days by 0.5 mg. Usual: 1-2 mg PO/IV/IM qhs.        Max: 6 mg/day.

Anti-Convulsants:

-   -   Carbamazepine-Initial: 200 mg bid. Titrate: May increase weekly        by 200 mg/day. Maint: 800-1200 mg/day. Max: 1200 mg/day.    -   Gabapentin (Neurontin®): Initial: 300 mg tid. Titrate: Increase        up to 1800 mg/day. Max: 3600 mg/day.    -   Barbiturates (Phenobarbital): 60-200 mg/day    -   Primidone: Day 1-3: 100-125 mg qhs. Day 4-6: 100-125 mg bid. Day        7-9: 100-125 mg tid. Day 10-Maint: 250 mg tid. Max: 500 mg qid.    -   Tiagabine: Initial: 4 mg qd. Titrate: May increase weekly by 4-8        mg until clinical response. Max: 56 mg/day given bid-qid

Anti-Depressants

-   -   Remeron (mirtazapine): Initial: 15 mg qhs. Titrate: May increase        every 1-2 weeks. Max: 45 mg/day.    -   Elavil (Amitriptyline): Initial: (Outpatient) 75 mg/day in        divided doses or 50-100 mg qhs. (Inpatient) 100 mg/day. Titrate:        (Outpatient) Increase by 25-50 mg qhs. (Inpatient) Increase to        200 mg/day. Maint: 50-100 mg qhs. Max: (Outpatient) 150 mg/day.    -   Tofranil (Imipramine): Depression: Initial: (Inpatient) 100        mg/day in divided doses. Titrate: Increase to 200 mg/day; up to        250-300 mg/day after 2 weeks if needed. (Outpatient) 75 mg/day.        Titrate: Increase to 150 mg/day. Maint: 50-150 mg/day. Max: 200        mg/day.    -   Norpramin (Desipramine): 100-200 mg/day given qd or in divided        doses. Max: 300 mg/day.    -   Pamelor (Nortripyline): 25 mg tid-qid. Max: 150 mg/day.    -   Sinequan (Doxepin): Very Mild Illness: Usual: 25-50 mg/day. Mild        to Moderate Severity: Initial: 75 mg/day. Usual: 75-150 mg/day.        Severely Ill: May increase up to 300 mg/day.    -   Anafranil (Clomipramine): 25 mg/day with meals. Titrate:        Increase within 2 weeks to 100 mg/day. Increase further over        several weeks. Max: 250 mg/day.    -   Trazodone: 150 mg/day in divided doses pc. Titrate: May increase        by 50 mg/day every 3-4 days. Max: (Outpatient) 400 mg/day,        (Inpatient) 600 mg/day.    -   Nefazodone: 100 mg bid. Usual: 300-600 mg/day.

Conventionally accepted effective dosages may also be found in the 2009edition of Physicians' Desk Reference (Thomson 2009), which isincorporated herein for its conventionally accepted effective dosages ofCNS active agents.

As mentioned above, another element of the pharmaceutical composition ofthe present invention is the combination of neuromodulators, (NMS) whichmay be referred to herein as “vagal neuromodulators.” Neuromodulators ofthe present invention will now be described in greater detail.

Neuromodulators modulate sensory receptors. Several types of sensoryreceptors are present on enteric neurons, including mechanoreceptors,chemoreceptors, thermal receptors, and possibly nociceptors (painreceptors). Low- and high-threshold mechanoreceptors are also present.The low-threshold receptors process normal input from the gut. Thehigh-threshold receptors only respond to higher pressures and distentionand may be important in mediating pain in patients with irritable bowelsyndrome (IBS). Psychological factors are also important in the patientwho develops IBS. Serotonin, cholecystokinin (CCK), neurokinins, andother chemicals stimulate chemoreceptors. Mechanoreceptors also containchemoreceptors. As a result, serotonin and other chemoreceptorstimulators serve a paracrine function and modify the response ofmechanoreceptors in the gut.

As used herein the “modulate, “neuromodulate,” and “stimulate” mean theability to regulate positively or negatively neuronal activity,preferably the activity of vagal nerve. These terms can be used to referto an increase, decrease, masking, altering, overriding or restoringneuronal activity. Modulation, neuromodulation, or stimulation ofneuronal activity affects psychological and/or psychiatric activity of asubject.

“Neuromodulator(s)” (NM) or “stimulating”, or “potentiating” agentscomprise medications, neurotransmitters and/or mimetics thereof,synthetic or natural peptides or hormones, neurotransmitters, cytokinesand other intracellular and intercellular chemical signals andmessengers, and the like. In addition, certain neurotransmitters,hormones, and other drugs are excitatory for some tissues, yet areinhibitory to other tissues. NM may be endogenous, natural orpharmaceutical agents that exert central nervous system (CNS) effects byinterfering with one or more of neurotransmitter systems. In particularcase the neuromodulator agent is referred to as an “excitatory” drug,this means that the drug is acting in an excitatory manner, although itmay act in an inhibitory manner in other circumstances and/or locations.Similarly, where an “inhibitory” drug is mentioned, this drug is actingin an inhibitory manner, although in other circumstances and/orlocations, it may be an “excitatory” drug. In addition, stimulation ofan area herein includes stimulation of cell bodies and axons in thearea, especially receptors of said neuromodulators localized on afferentor efferent vagal nerve fibers.

“Combination of” or “In combination with” a neuromodulator of thepresent invention refers to co-administration of the two agents.Co-administration may occur either concurrently or sequentially.

In the context of the present invention, neuromodulation of centrallyactive agents refers to pharmaceutical stimulation of vagal afferentand/or vagal efferent receptors by the administration of combinations ofneuromodulators in the formulations provided below. The vagalneuromodulator of the present invention stimulates the vagal afferentand/or vagal efferent receptors when administered as part of thepharmaceutical composition. The vagal neuromodulator comprisesmechanoreceptor stimulators, chemoreceptor stimulators, a vagal efferentstimulator, a vagal afferent stimulator and a nociceptor stimulator.Neuromodulators may also be used in combination with electricalstimulation.

Mechanoreceptors sense mechanical events in the mucosa, musculature,serosal surface, and mesentery. They supply both the enteric minibrainand the CNS with information on stretch-related tension and musclelength in the wall and on the movement of luminal contents as they brushthe mucosal surface. Whether the neuronal cell bodies of intramuscularand mucosal mechanoreceptors belong to dorsal root ganglia, entericganglia, or both, is uncertain. Mechanoreceptor stimulator(s) of thepresent invention stimulate the mechanoreceptors and comprisemucomodulators, surfactants and vasoactive agents.

Preferable mechanoreceptors stimulators comprise mucomodulators andvaso-active agents.

Mucomodulators include N-acetyl-cysteine are thiols with afree-sulfhydryl group. They are assumed to break disulfide bonds betweengel-forming mucins and thus reduce mucus viscosity. Mucokinetic agentsare thiols with a blocked sulfhydryl group. Expectorants such asguaifenesin (GUA) increase mucus secretion. They may act as irritants togastric vagal receptors, and recruit efferent parasympathetic reflexesthat cause glandular exocytosis of a less viscous mucus mixture.

Furthermore, the pharmaceutical compositions may comprise mucomodulatorsthat reduce the viscosity of the gastric mucosa, thereby acceleratingthe exposure of gastric mucosa to chemoreceptor neuromodulator, such asvasoactive agent or neurotransmitter. Such mucomodulators are, forexample, reducing agents such as N-acetyl cysteine, dithiothreitol, GUA,citric acid or mannitol.

Suitable mucomodulators also comprise expectorants, including ambroxol,ammonium bicarbonate, ammonium carbonate, bromhexine, calcium iodide,carbocysteine, guaiacol, guaiacol benzoate, guaiacolcarbonate, guaiacolphosphate, guaifenesin, guaithylline, hydriodic acid, iodinatedglycerol, potassium guaiacolsulfonate, potassium iodide, sodium citrate,sodium iodide, storax, terebene, terpin, and trifolium.

Additional mechanoreceptor modulators are surfactants. Surfactantsmodulate surface tension providing hypotension wherein the surfacetension is less than 10; or hypertension (the surface tension of about10 to 70 dynes/cm). Surfactants in this invention may be selected fromthe following groups: PEGS (Polyethylene glycols); Sodium LaurylSulfates; Sorbitan esters; Polysorbates and Benzalkonium Chlorides.Polysorbate is selected from the group consisting of: Polysorbate 20(polyoxethylene (20) sorbitan monolaurate), Polysorbate 40(polyoxethylene (20) sorbitan monopalmitate), and Polysorbate 60(polyoxyethylene (20) sorbitan monostearate). Other surfactants can beselected from such groups as dispersing agents, solubilizing agents,emulsifying agents, thickening and spreading agents.

Neuromodulators of the present invention also comprise chemoreceptorstimulators which will now be described. Chemoreceptor stimulators maybe pH modulators, secretagouges, adrinomimetics, xanthines,cholecystokinins and gastric agonists. Chemoreceptors are sensitive tobiochemical neurotransmitters, hormones, ATP-receptor modulators and pHand generator information on nutrient concentration, osmolarity and pHin the luminal contents. The actions of extracellular ATP are known tobe mediated by specific cell surface receptors, P2-purinoceptors. Thesereceptors are subdivided into two families: P2x and P2y. Vaso-active,oxygen, ATP-modulators, hypertensive, including succinic acid and otherKrebs cycle intermediates, are also putative ATP modulators, andtherefore neuromodulators of chemoreceptors. Chemoreceptor stimulatorsof the present invention are neurotransmitters, neuropeptides and otheragents that stimulate chemoreceptors localized in afferent nerves.

Chemoreceptor stimulators of the present invention compriseadrenomimetics (ADR), (e.g. adrenaline, noradrenaline, adrianol,phenylephrine/metazone (PHE), ephedrine, ethylephrine, etc.) andpolypeptides (e.g. glucogon, angiotensin, octapressin, etc.) that aremost often used to affect arterial blood pressure by either stimulatingalpha-adrenergic receptors or directly on the visceral muscles of thevascular wall. PHE may be classified functionally as: “Vasoactive” or“Vasoconstricting” agent and/or “Hypertensive agent” (refers to any of aclass of pharmacological agents which increase blood pressure), examplesof appropriate hypertensive agents include, without limitation,phenylephrine and sodium chloride (NaCl). “Bronchodilators” includesalbutamol (albuterol), phenylephrine, isoproterenol, and propranolol.Most adrenomimetics are vaso-active agents and selectively stimulateadrenoreceptors, causing arterial constriction and increase in systolicand diastolic pressure. PHE practically does not have any cardiostimulating effect. Other vasoactive agents, such as Neuropeptide Y(NPY), vasodilators (Papaverin, PGE2; Drovatravin, phentolamine) andvasoconstrictors (PHE, NPY derivatives and analogs and Toxins) maypotentially modulate vagal afferents as well. Unlike adrenaline andnoradrenaline, PHE is not a catecholamine and is not influenced by theenzyme O-methyltransferase; therefore, it is more stable and has aprolonged effect. Since adrenomimetic medicaments with polypeptidestructures have a short-lived effect, to achieve prolonged effect theyare injected in the form of perfusion. For example, PHE (bran-Mezaton)has an anti-hypotensive effect that usually lasts for approximately 20minutes after a single intravascular injection. Adrenomimetics, amongthem PHE, have some common shortcomings, as they increase tissue oxygenconsumption, cause metabolic acidosis, may cause arrhythmia (especiallyduring general anesthesia), and exert an exciting influence on the CNS.

Another example of chemoreceptor stimulators is xanthines which includeephedrine, caffeine, theophylline and theobromine. The potency of thesecompounds has generally been ranked according to the ephedrine,caffeine, and theobromine series; however, they are not identical.

CCK/gastrin agonists or analogs thereof will now be discussed.Heptapeptide, octapeptide and nonapeptide analogs of CCK-8 act as CCKagonists for stimulating gallbladder contractions, arresting thesecretion of gastric acid, and treating convulsions. Hepta- andoctapeptides with sulfate ester groups which are useful for treatingobesity. Pentagastrin (PG)(β-alanyl-L-tryptophyl-L-methionyl-L-aspartyl-L-phenyl-alanyl amide; SEQID NO:2) is a pentapeptide containing the carboxyl terminal tetrapeptideof gastrin.

Additional chemoreceptor stimulators are pH modulators. Selected pHmodulators are anti-acid drugs and parietal cells activators. Thepreferred anti-acid drugs are histamine antagonists. According to thepresent invention, Proton pump inhibitors (PPIs) are compounds thatinhibit the activity of the H⁺/K⁺-adenosine triphosphatase (ATPase)proton pump in the gastric parietal cells. In its pro-drug form, PPI isnon-ionized and, therefore, is capable of passing through the cellularmembrane of the parietal cells. Once reaching the parietal cells, thenon-ionized PPI moves into the acid-secreting portion of activatedparietal cells, the secretory canaliculus. The PPI trapped in thecanaliculus becomes protonated, and is thus converted into the activesulfenamide form that can form disulfide covalent bonds with cysteineresidues in the alpha subunit of the proton pump, thereby irreversiblyinhibiting the proton pump. The “parietal cell activators” disclosed inU.S. Pat. Nos. 6,489,346; 6,645,988; and 6,699,885 include, for example,chocolate, sodium bicarbonate, calcium, peppermint oil, spearmint oil,coffee, tea and colas, caffeine, theophylline, theobromine and aminoacids residues. As indicated, all of these proposed parietal cellactivators induce the release of endogenous gastrin that exerts bothinhibitory and stimulatory effects on acid secretion by activating bothCCK-A and CCK-B receptors.

pH modulators of the present invention include for example: sodium orpotassium bicarbonate, magnesium oxide, hydroxide or carbonate,magnesium lactate, magnesium glucomate, aluminum hydroxide, aluminium,calcium, sodium or potassium carbonate, phosphate or citrate, di-sodiumcarbonate, disodium hydrogen phosphate, a mixture of aluminum glycinateand a buffer, calcium hydroxide, calcium lactate, calcium carbonate,calcium bicarbonate, and other calcium salts. It is noted that whilesodium bicarbonate dissolves easily in water, calcium carbonate iswater-insoluble and is slowly soluble only in acidic environment.

Chemoreceptor stimulators of the present invention also include thefollowing pH modulators, which may be used alone or in combination:alumina, calcium carbonate, and sodium bicarbonate; alumina andmagnesia; alumina, magnesia, calcium carbonate, and simethicone;alumina, magnesia, and magnesium carbonate; alumina, magnesia, magnesiumcarbonate, and simethicone; alumina, magnesia, and simethicone; alumina,magnesium alginate, and magnesium carbonate; alumina and magnesiumcarbonate; alumina, magnesium carbonate, and simethicone; alumina,magnesium carbonate, and sodium bicarbonate; alumina and magnesiumtrisilicate; alumina, magnesium trisilicate, and sodium bicarbonate;alumina and simethicone; alumina and sodium bicarbonate; aluminumcarbonate, basic; aluminum carbonate, basic, and simethicone; aluminumhydroxide; calcium carbonate and magnesia; calcium carbonate, magnesia,and simethicone; calcium carbonate and simethicone; calcium andmagnesium carbonates; magaldrate; magaldrate and simethicone; magnesiumcarbonate and sodium bicarbonate; magnesium hydroxide; magnesium oxide.

Additional chemoreceptor stimulators are secretagouges: “gastric acidstimulant” refers to any agent that is capable of stimulating gastricacid secretion via direct or indirect effect on parietal cells.Preferred gastric acid stimulants to be used in combination with PG or aPG analogue are small dicarboxylic and tricarboxylic acids such assuccinic acid, succinic acid salts and esters, maleic acid, citric acidand fumaric acid, or the salt thereof. Additional secretagouges compriseetyron (S-ethylisothiouronium bromide), S-alkylisothiouroniumderivatives, and S-ethylisothiouronium diethylphosphate, variously fortreatment of high blood pressure, hyperoxia and acute hypotension,(e.g., shock conditions and chronic hypotension or oxygen poisoning).

Osmoreceptor stimulators are additional stimulants of chemoreceptors. Todescribe preferable osmoreceptor neuromodulators in this invention,osmolarity is defined as hypotonic or hypertonic when diluted in gastricfluid is lower or higher respectively than isotonic composition.Preferably, the pharmaceutical composition of the present inventionstimulates the vagal gastric afferents when lower than 190 mOsm orhigher than 270 mOsm. The isotonic nature of the composition whendiluted in gastic fluid (˜500 mL) has 190 mOsm-to 270 mOsm. Ifhyperosmotic, the composition further comprises: osmotic pressure of thecomposition between about 300 mOsm/kg to 880 mOsm/kg (NaCl equivalencyof the solution is between about 0.9% NaCl to 3.0% NaCl). Ifhypo-osmotic, the composition further comprises: osmotic pressure of thecomposition less than 300 mOsm/kg (NaCl equivalency of the solution isless than 0.9% NaCl). The osmoreceptor stimulator may be salts,sorbitol, sucrose; carbohydrates may comprise maltodextrins, glucosesyrups, hydrolyzed starches, soluble starches, monosaccharides likeglucose, fructose, galactose, mannose, etc. and disaccharides likesucrose and lactose. Mixtures may also be used, but the osmotic value ofthe final product should outside of isotonic range 250-380 mOsm/l.

Neuromodulators further comprise vagal efferent stimulators.Neuromodulators cross the blood brain barrier and directly or indirectlyaffect the release of neurotransmitters, or exhibit excitatory orinhibitory action potential by themselves. Preferable vagal efferentneuromodulators in this invention are secretagouoges, such as: CCK,pilocarpine, succinic acid, secretin, TRH, sympatheticomimetics andanalogues thereof. Some examples of sympatheticomimetics includetheophylline, ephedrine, pseudoephedrine, and synephrine.

The GABA modulators are also suitable for use in the present inventionas a vagal neuromodulator. GABA modulators include GVG, GHB, muscimol,progabide, riluzole, baclofen, gabapentin (Neurontin), vigabatrin,tiagabine (Gabitril®), lamotrigine (Lamictal®), pregabalin, topiramate(Topamax), a prodrug thereof or a pharmaceutically acceptable salt ofthe GABA modulator or prodrug thereof. As will be recognized by those ofordinary skill in the art after becoming familiar with the teachingsherein, other GABA agonists are also useful in the combinations,pharmaceutical compositions, methods and kits generated from thisinvention.

Also included as vagal efferent modulators are CNS stimulants, such ascaffeine or other botanical stimulating extracts. The neuromodulators ofthe present invention include nociceptor stimulators, which includeopioids. Preferred opioids interact with the μ-opioid receptor, theK-opioid receptor, or both. Preferably, opioids are opioid-receptoragonists, including morphine, loperamide and loperamide derivatives.Examples of suitable opioids for use with the invention includealfentanil, allylprodine, alphaprodine, anileridine, benzylmorphine,benzitramide, nor-binaltorphimine, bremazocine, buprenorphine,butorphanol, clonitazene, codeine, CTOP, DAMGO, desomorphine,dextromoramide, dezocine, diampromide, dihydrocodeine, dihydrocodeineenol acetate, dihydromorphine, dimenoxadol, dimepheptanol,dimethylthiambutene, dioxaphetyl butyrate, dipipanone, diprenorphine,DPDPE, eptazocine, ethoheptazine, ethylketocyclazocine,ethylmethylthiambutene, etonitazene, etorphine, fentanyl, hydrocodone,hydromorphone, hydroxypethidine, isomethadone, ketobemidone,levorphanol, lofentanil, loperamide, meperidine, meptazinol,metazocaine, methadone, metopon, morphine, myrophine, nalbuphine,naltrindole, benzoylhydrazone, naltrexone, narceine, nicomorphine,norlevorphanol, normethadone, normorphine, norpipanone, opium,oxycodone, oxymorphone, papavereturn, papaverine, pentazocine,phenadoxone, phenazocine, phenoperidine, piminodine, pirtramide,proheptazine, promedol, propiram, propoxyphene, remifentanil,spiradoline, sufentanil, tilidine, U50,488, and U69,593, amiphenazole,cyclazocine, levallorphan, nalmefene, nalorphine, naloxone, andnaltrexone or pharmaceutically-acceptable salts thereof, or mixturesthereof. Examples of peptide opioids include, but are not limited toenkephalin, deltorphin, Morphiceptin, or pharmaceutically-acceptablesalts thereof, or mixtures thereof.

Further examples of opioids include (1) opium alkaloids, such asmorphine (Kadian®, Avinza®), codeine, and thebaine; (2) semisyntheticopioid derivatives, such as diamorphine (heroin), oxycodone (OxyContin®,Percodan®, Percocet®), hydrocodone, dihydrocodeine, hydromorphine,oxymorphone, and nicomorphine; (3) synthetic opioids, such as (a)pheylheptylamines, including methadone and levo-alphacetylmethadol(LAAM), (b) phenylpiperidines, including pethidine (meperidine),fentanyl, alfentanil, sufentanil, remifentanil, ketobemidone, andcarfentanyl, (c) diphenylpropylamine derivatives, such as propoxyphene,dextropropoxyphene, dextromoramide, bezitramide, and piritramide, (d)benzomorphan derivatives, such as pentazocine and phenzocine, (e)oripavine derivatives, such as buprenorphine, (f) morphinan derivatives,such as butorphanol and nalbufine, and miscellaneous other syntheticopioids, such as dezocine, etorphine, tilidine, tramadol, loperamide,and diphenoxylate (Lomotil®).

Nociceptor stimulators of the present invention comprise analgesics,including aceclofenac, acetaminophen, acetaminosalol, acetanilide,acetylsalicylsalicylic acid, alclofenac, alminoprofen, aloxiprin,aluminum bis(acetylsalicylate), aminochlorthenoxazin,2-amino-4-picoline, aminopropylon, aminopyrine, ammonium salicylate,amtohnetin guacil, antipyrine, antipyrine salicylate, antrafenine,apazone, aspirin, benorylate, benoxaprofen, benzpiperylon, benzydamine,bermoprofen, bromfenac, p-bromoacetanilide, 5-bromosalicylic acidacetate, bucetin, bufexamac, bumadizon, butacetin, calciumacetylsalicylate, carbamazepine, carbiphene, carsalam,chlorthenoxazin(e), choline salicylate, cinchophen, ciramadol,clometacin, clonixin, cropropamide, crotethamide, dexoxadroldifenamizole, difiunisal, dihydroxyaluminum acetylsalicy, late,dipyrocetyl, dipyrone, emorfazone, enfenamic acid, epirizole,etersalate, ethenzamide, ethoxazene, etodolac, felbinac, fenoprofen,floctafenine, flufenamic acid, fluoresone, flupirtine, fluproquazone,flurbiprofen, fosfosal, gentisic acid, glafenine, ibufenac, imidazolesalicylate, indomethacin, indoprofen, isofezolac, isoladol, isonixin,ketoprofen, ketorolac, p-lactophcnetide, lefetamine, lomoxicam,loxoprofen, lysine acerylsalicylate, magnesium acetylsalicylate,methotrimeprazine, metofoline, mofezolac, morazone, morpholinesalicylate naproxen, nefopam, nifenazone,5′-nitro-2′-propoxyacetanilide, parsalmide, perisoxal, phenacetin,phenazopyridine hydrochloride, phenocoll, phenopyrazone, phenylacetylsalicylate, phenyl salicylate, phenyramidol, pipebuzone,piperylone, propacetamol, propyphenazone, ramifenazone, rimazoliummetilsulfate, salacetamide, salicin, salicylamide, salicylamide o-aceticacid, salicylsulfuric acid, salsalate, salverine, simetride, sodiumsalicylate, suprofen, talniflumate, tenoxicam, terofenamate,tetrandrine, tinoridine, tolfenamic acid, tramadol, tropesin, viminol,xenbucin, and zomepirac.

Additional nociceptor stimulators are antitussive agents includingalloclamide, amicibone, benproperine, benzonatate, bibenzonium bromide,bromoform, butamirate, butethamate, caramiphen ethanedisulfonate,carbetapentane, chlophedianol, clobutinol, cloperastine, codeine,codeine methyl bromide, codeine n-oxide, codeine phosphate, codeinesulfate, cyclexanone, dimethoxanate, dropropizine, drotebanol,eprazinone, ethyl dibunate, ethylmorphine, fominoben, guaiapate,hydrocodone, isoaminile, levopropoxyphene, morclofone, narceine,mormethadone, noscapine, oxeladin, oxolamine, pholcodine, picoperine,pipazethate, piperidione, prenoxdiazine hydrochloride, racemethorphan,sodium dibunate, tipepidine, and zipeprol.

Additional neuromodulators, including some vagal afferent stimulators,are listed below:

Hormones and Neurosteroids and analogs thereof, includingthyrotropin-releasing hormone (TRH) Receptor. It was shown that TRHexcitatory action in the DMN is potentiated by co-released prepro-TRH—flanking peptide, Ps4 and 5-HT, and inhibited by a number of peptidesinvolved in the stress/immune response and inhibition of food-intake(Tache Y Auton Neurosci. 2006 Apr. 30; 125(1-2):42-52.). Brainstem TRHisbelieved to play a physiological role in the central vagal stimulationof gastric myenteric cholinergic neurons in response to several vagaldependent stimuli. Also included are neurosteroids, such asdehydroepiandrosterone and its salts, that interact with the GABAAreceptor complex.

Cytokines, such as TNF-α, interleukin (IL)-1beta, IL-6 and IL-18—werealso reported to modulate vagal nerve-related activity.

Narcotic and non-narcotic analgesics, such as Metamizol (sodiumN-(1,5-dimethyl-3-oxo-2-phenylpyrazolin-4-yl)-N-methylamino-methylsulphonate;Dipyrone). Narcotic anagetics, such as morphine and other opioids, areknown vagal afferent stimulators. Dopram, doxapram hydrochloride, orchlorobutanol are known to potentiate hexobarbital induced narcosis.)

Hypertensive agents, such as clonidine, a hypertensive drug, andPirbuterol, treatment for congestive heart failure.

Excitatory neurotransmitter modulators (i.e., norepinephrine,epinephrine, glutamate, acetylcholine, serotonin, dopamine, ginseng),agonists thereof, and agents that act to increase levels of anexcitatory neurotransmitter(s) (i.e., edrophonium; Mestinon; trazodone;SSRIs (i.e., flouxetine, paroxetine, sertraline, citalopram andfluvoxamine); tricyclic antidepressants (i.e., imipramine,amitriptyline, doxepin, desipramine, trimipramine and nortriptyline),monoamine oxidase inhibitors (i.e., phenelzine, tranylcypromine,isocarboxasid)), generally have an excitatory effect on neural tissue,while inhibitory neurotransmitters (i.e., dopamine, glycine, andgamma-aminobutyric acid (GABA)), agonists thereof, and agents that actto increase levels of an inhibitory neurotransmitter(s) generally havean inhibitory effect. Dopamine acts as an excitatory neurotransmitter insome locations and circumstances, and as an inhibitory neurotransmitterin other locations and circumstances. Antagonists of inhibitoryneurotransmitters (i.e., bicuculline) and agents that act to decreaselevels of an inhibitory neurotransmitter(s) have been demonstrated toexcite neural tissue, leading to increased neural activity. Excitatoryneurotransmitter antagonists (such as prazosin, and metoprolol) andagents that decrease levels of excitatory neurotransmitters may inhibitneural activity.

Carbidopa/levodopa or dopamine agonists include ropinirole, pramipexoleand cabergoline, bromocriptine mesylate (Parlodel®), pergolide mesylate(Permax®), pramipexole dihydrochloride (Mirapex®), and ropinirolehydrochloride (Requip™).

Anesthetics include enflurane, halothane, isoflurane, methoxyflurane,nitrous oxide, etomidate, ketamine, methohexital, propofol, andthiopental.

“Antispasmodic” means any compound that suppresses muscle spasms.Spasmolytics or antispasmodics include methocarbamol, guaifenesin,diazepam, dantrolene, phenyloin, tolterodine, oxybutynin, flavoxate, andemepronium. Off-label use of diazepam (Valium®), very sedating attherapeutic levels, may be habit-forming. Pharmacotherapy may be usedfor acute musculoskeletal conditions when physical therapy isunavailable or has not been fully successful. Antispasmodics for suchtreatment include cyclobenzaprine, carisoprodol, orphenadrine, andtizanidine (Zanaflex®). Applicable conditions include acute back or neckpain, and pain after an injury. Spasm may also be seen in movementdisorders featuring spasticity in neurologic conditions such as cerebralpalsy, multiple sclerosis, and spinal cord disease. For example,clonazepam (Klonopin®) is often used in the therapy for multiplesclerosis for the treatment of tremors, pain, and spasticity.Furthermore, medications such as baclofen, tizanidine, and dantrolenehave been used in treatment for spastic movement disorders.

Specifically, oral baclofen is often used as a first line drug formanagement of spasticity. Such treatment often produces a favorablereduction in tone. Generally, treatment is started at a low dose andslowly titrated up to minimize sedation and identify the lowesteffective dose. However, one can start standard dose without sedationwith the claimed invention.

Antiemetics or antinauseants include, but are not limited to,promethazine (Phenergan®), metoclopramide (Reglan®), cyclizine(Merezine®), diphenhydramine (Benadryl®), meclizine (Antivert®,Bonine®), chlorpromazine (Thorazine®), droperidol (Inapsine®),hydroxyzine (Atarax®, Vistaril®), prochlorperazine (Compazine®),trimethobenzamide (Tigan®), cisapride; h2-receptor antagonists, such asnizatidine, ondansetron (Zofran®), corticosteriods, 5-Hydroxytryptamineantagonists, such as dolasetron (Anzemet®), granisetron (Kytril®),ondansetron (Zofran®), tropisetron; dopamine antagonists, such asdomperidone (Motilium®), droperidol (Inapsine®), haloperidol (Haldol®),chlorpromazine (Thorazine®); Antihistamines (5HT2 receptor antagonists),such as cyclizine (Antivert®, Bonine®g, Dramamine®, Marezine®,Meclicot®, Medivert®), diphenhydramine, dimenhydrinate (Alayert®,Allegra®, Dramanate®) dimenhydrinate (Driminate®); and cannabinoids,such as marijuana and marinol.

“Pharmaceutically acceptable salts” includes both pharmaceuticallyacceptable acid addition salts and pharmaceutically acceptable cationicsalts. The expression “pharmaceutically-acceptable cationic salts” isintended to define but is not limited to such salts as the alkali metalsalts, (e.g., sodium and potassium), alkaline earth metal salts (e.g.,calcium and magnesium), aluminum salts, ammonium salts, and salts withorganic amines such as benzathine (N,N′-dibenzylethylenediamine),choline, diethanolamine, ethylenediamine, meglumine (N-methylglucamine),benethamine (N-benzylphenethylamine), diethylamine, piperazine,tromethamine (2-amino-2-hydroxymethyl-1,3-propanediol) and procaine. Theexpression “pharmaceutically-acceptable acid addition salts” is intendedto define, but is not limited to, such salts as hydrochloride,hydrobromide, sulfate, hydrogen sulfate, phosphate, hydrogen phosphate,dihydrogenphosphate, acetate, succinate, citrate, methanesulfonate(mesylate) and p-toluenesulfonate (tosylate) salts. Whenever CNS activeagents, neuromodulators or any other compounds are described herein,they also include pharmaceutically acceptable salts and prodrugsthereof.

The pharmaceutical compositions of the present invention may alsocomprise other excipients and pharmaceuticals. Excipients for topicalapplications may comprise antibiotics, analgesics, antifungal agents,non-steroidal anti-inflammatory agents, anti-tussive agents,expectorants, glucocorticoids, vitamins, anti-oxidants, flavoringagents, sweetening agents, osmotic agents, moisturizers, emollients,buffering agents, solubilizing agents, penetration agents, protectants,surfactants, and propellants, thinking agents, parietal cells activatorsand other conventional systemic or topical pain relief therapies,analgesics, and pharmaceuticals.

Anti-oxidants may include ascorbic acid, sodium ascorbate, sodiumbisulfite, sodium thiosulfate, 8-hydroxy quinoline, and N-acetylcysterine.

Suitable flavoring agents include oil of spearmint, peppermint,wintergreen, sassafras, clove, sage, eucalyptus, marjoram, cinnamon,lemon, and orange, and methyl salicylate.

Suitable sweetening agents include sucrose, lactose, maltose, sorbitol,xylitol, sodium cyclamate, perillartine, AMP (aspartyl phenyl alanine,methyl ester), and saccharine.

Suitable preservatives include quaternary ammonium compounds, such asbenzalkonium chloride, benzethonium chloride, cetrimide, dequaliniumchloride, and cetylpyridinium chloride; mercurial agents, such asphenylmercuric nitrate, phenylmercuric acetate, and thimerosal;alcoholic agents, for example, chlorobutanol, phenylethyl alcohol, andbenzyl alcohol; antibacterial esters, for example, esters ofpara-hydroxybenzoic acid; and other anti-microbial agents such aschlorhexidine, chlorocresol, and polymyxin.

“Therapeutically effective amount” is used herein with respect to a drugdosage, shall mean that dosage that provides the specificpharmacological response for which the drug is administered in asignificant number of subjects in need of such treatment. It isemphasized that “therapeutically effective amount,”, administered to aparticular subject in a particular instance will not always be effectivein treating the diseases described herein, even though such dosage isdeemed a “therapeutically effective amount” by those of ordinary skillin the art. “Therapeutically effective amount” also includes an amountthat is effective for prophylaxis. It is to be further understood thatdrug dosages are, in particular instances, measured as oral dosages, orwith reference to drug levels as measured in blood.

As used herein “include” and “including” mean include without limitationand including without limitation.

The pharmaceutical compositions and methods of the present inventionmodulate the vagal tone of the autonomic nervous system, by modulatingCNS activity through activation/stimulation of afferent inputs from thegastric vagal nerves innervating the upper gastrointestinal tract. Thisinvention therefore permits the conventionally accepted effective doseof the CNS active agent to be reduced to a lower, yet therapeuticallyeffective amount, by combining administration of the CNS active agentwith at least two vagal neuromodulators such that the neuromodulatorsare released when the CNS active agent is present in systemiccirculation, typically reductions of about 20 to about 95% may beobtained using the pharmaceutical composition and method of the presentinvention. For example, the reduction in CNS active agent is preferablyat least about 40% and more preferably at least about 50%, or at least60% of the conventionally accepted effective dose. The present inventionoffers the ability to affect neuronal function by delivering theneuromodulator to vagal nerve-afferent or -efferent receptors in orderto treat the CNS-related disorder.

In another embodiment, the combination of the CNS active agent, alongwith at least two vagal neuromodulators, one of which is amechanoreceptor, allows the conventionally accepted effective dose to beused without interfering with efficacy, but with reduced side-effectsassociated with use of the CNS active agent, including sedation,somnolence, sleepnece, memory impairment, amnesia, impairment ofcognitive and learning function, ataxia; impaired night sleep/dayalertness, impaired memory, impaired concentration, impaired appetite,drowziness, hypotention, fatigue, kinetic disorders, catalepsy, movementdisorders, bowel irritation and impaired reaction, and such otherside-effects as are discussed herein.

Using the CNS active agent in conjunction with neuromodulators of thepresent invention, the conventionally accepted effective dose ranges ofCNS active agents may be reduced about 20-95%, preferably about 20 toabout 40% and more preferably about 20 to about 50%. The term “inconjunction with” means that when the CNS and the neuromodulators areadministered in separate dosage forms, there is at least somechronological overlap in their physiological activity. Thus the CNS andNM can be administered simultaneously and/or sequentially. Sequentialrelease would be used if it is required to synchronize the release ofthe CNS agent with the action of the neuromodulators by delaying therelease of neuromodulator in the stomach (ex. by using polymeric coatedneuromodulator particles). The pharmaceutical combinations may beadministered on a regimen of up to 6 times per day, preferably 1 to 4times per day, and ideally once to twice a day. “Synchronize” or“synchronization” as used herein means timing the release of the CNSactive agent in relation to the release of the vagal neuromodulators sothat there is some chronological overlap in physiological activity.Synchronization may be defined by reference to the Tmax of both the CNSactive agent and the vagal neuromodulator(s) in relation to one another.Thus, Delay Time (in administration or release ofneuromodulator(s))=(TmaxCNS active agent−TmaxNM)+30 minutes; preferably,Delay Time of the NM=(TmaxCNS active agent−TmaxNM)+20 minutes; morepreferably, Delay Time of the NM=(TmaxCNS active agent−TmaxNM)+10minutes. Stated another way, TmaxNM=TmaxCNS active agent±30 minutes;preferably, TmaxNM=TmaxCNS active agent±20 minutes; more preferably,TmaxNM=Tmax CNS active agent±10 minutes. In a case wherein the Tmax ofthe CNS agent is greater than the Tmax of the NM, release of the NMwould be preferably delayed. For example, wherein delay in the releaseof the NM is within 30 minutes, more preferably within about 20 minutes,and most preferably within about 10 minutes of the difference of theTmaxCNS and TmaxNM. In this embodiment, “about” typically means withinone or two minutes, more preferably within a minute of the stated time.

Formulation and dosage of the pharmaceutical composition will now bedescribed, with reference to a time-release component that makespossible overlapping effectiveness of the CNS active agent and theneuromodulators as are discussed above.

The compositions and combinations of this invention can be administeredby oral, parenteral (e.g., intramuscular, intraperitoneal, intravenous,or subcutaneous injection, or through an implant), nasal, vaginal,rectal, sublingual, or topical routes of administration and can beformulated with pharmaceutically acceptable carriers, vehicles, ordiluents to provide dosage forms appropriate for each route ofadministration.

Oral dosage forms will now be described. The active ingredients of thepresent invention are preferably formulated in a single oral dosage formcontaining all active ingredients. The compositions of the presentinvention may be formulated in either solid or liquid form. Embodimentsof the form of the pharmaceutical composition of the present inventionare set forth below:

-   -   Film coated tablets containing morphine, PHE and sorbitol, and        following excipients: microcrystalline cellulose (Avicel),        magnesium stearate, starch; hydroxypropyl methycellulose.    -   Hard gelatin capsules comprising morphine hydrochloride,        pilocarpine, sorbitol and lactose monohydrate    -   Effervescent tablets containing morphine sulfate, GUA and PHE        and the excipients: citric acid, sodium bicarbonate,        microcrystalline cellulose, mannitol, sodium citrate    -   Enteric coated tablets containing morphine sulfate, carbachol        and sorbitol and the excipients: microcrystalline cellulose,        lactose monohydrate, cellulose acetate phthalate, tween 80,        triacetin    -   Gastroretentive tablets containing morphine sulfate, PHE and        GUA, and the excipients: succinic acid and derivatives of        thereof, HPMC, guar gum, sodium bicarbonate, stearic acid,        magnesium stearate, talc    -   Orodispersible tablets: morphine sulfate, carbachol and        sorbitol, crosspovidone, mannitol, hydroxypropyl cellulose,        magnesium stearate, microcrystalline cellulose, flavoring agent

In one embodiment, CNS active agent particles, and particles from atleast two vagal neuromodulators are formulated in a single solid dosageform, such as multi-layered tablets, suspension tablets, effervescenttablets, powder, pellets, granules or capsules comprising multiplebeads. In yet another embodiment, the CNS active agent andneuromodulators are formulated in a single liquid dose, such as asuspension containing all active ingredients or dry suspension to bereconstituted prior to use.

In single dose form, the CNS active agent particles and neuromodulatorparticles may be coated with either enteric pH-dependent release polymeror non-enteric, time-dependent release polymer in order to synchronizethe local biological activity of the vagal neuromodulator (ex. GUAor/and PHE in the GI lumen) and the systemic effect of the CNS activeagent on the CNS target.

For example, if coated CNS agent particles are used, leading to delayedor slowed absorption in the bloodstream, it is desirable that theneuromodulator particles are coated as well, in order to delayneuromodulator release. In one embodiment, the CNS active agentparticles are coated with a thick non-enteric layer so as the release ofthe CNS active agent is delayed between about 20 to 80 minutes(preferably, about 25-75 min/or about 30-60 min), and the neuromodulatorparticles are coated with a thin non-enteric polymer layer so as todelay the release of the neuromodulators by about 5-60 min (preferably,about 8-45 min/or about 10-30 min). These conditions permit vagalafferent activation of the gastric milieu by the vagal neuromodulatorconcurrently with the achievement of a pharmacological “effective” CNSagent plasma concentration.

In another embodiment, if the delayed release of CNS agent isapplicable, GUA and PSE may be applied at such release formulation,wherein Tmax of GUA and PSE in blood allows optimal concentration ofboth neuromodulators at the site of vagal afferent stimulation activity.The Tmax of CNS agent will allow release of CNS agent once the vagalafferent neurons have already been stimulated and therefore, willprevent sedation-related effects associated with the CNS agent. Forexample, delayed release of CNS agent up to approximately one hour maybe synchronized with immediate-release GUA and PSE, reachingsynchronization once both neuromodulators already available at the siteof their vagal afferent action and potentiate/synergize mechanoreceptoractivity putatively on the gastric vagal afferents.

In one embodiment of the current invention, the preferred NM is GUA(guaifenesin, a mechanoreceptor stimulator), PHE (chemoreceptorstimulator), SA (succinic acid, vagal efferent stimulant), morphine(nociceptor stimulator) or a combination thereof.

Non-enteric time-dependent release polymers include, for example, one ormore polymers that swell in the stomach with the absorption of waterfrom the gastric fluid, thereby increasing the size of the particles tocreate a thick coating layer. The time-dependent release coatinggenerally possesses erosion and/or diffusion properties that areindependent of the pH of the external aqueous medium. Thus, the activeingredient is slowly released from the particles by diffusion orfollowing slow erosion of the particles in the stomach.

The erosion properties of the polymer in the stomach resulting from theinteraction of fluid with the surface of the dosage form are determinedmainly by the polymer molecular weight and the drug/polymer ratio. Inorder to ensure a delay of between about 10 min to about 60 min in therelease of CNS active agent and the neuromodulators, it is preferredthat the molecular weight of the polymer be in the range of ˜10⁵ to ˜10⁷gram/mol. Furthermore, it is preferred that the CNS active agent orneuromodulator/polymer ratio be in the range of ˜2:3 to ˜9:1, preferably˜3:2 to 9:1, and ideally ˜4:1 to 9:1.

Suitable non-enteric time-dependent release coatings are for example:film-forming compounds such as cellulosic derivatives, such asmethylcellulose, hydroxypropyl methylcellulose (HPMC),hydroxyethylcellulose, and/or acrylic polymers including the non-entericforms of the Eudragit brand polymers. Other film-forming materials maybe used alone or in combination with each other or with the ones listedabove. These other film forming materials generally includepoly(vinylpyrrolidone), Zein, poly(ethylene glycol), poly(ethyleneoxide), poly(vinyl alcohol), poly(vinyl acetate), and ethyl cellulose,as well as other pharmaceutically acceptable hydrophilic and hydrophobicfilm-forming materials. These film-forming materials may be applied tothe substrate cores using water as the vehicle or, alternatively, asolvent system. Hydro-alcoholic systems may also be employed to serve asa vehicle for film formation.

Other materials suitable for making the time-dependent release coatingof the invention include water soluble polysaccharide gums such ascarrageenan, fucoidan, gum ghatti, tragacanth, arabinogalactan, pectin,and xanthan; water-soluble salts of polysaccharide gums such as sodiumalginate, sodium tragacanthin, and sodium gum ghattate; water-solublehydroxyalkylcellulose wherein the alkyl member is straight or branchedof 1 to 7 carbons such as hydroxymethylcellulose, hydroxyethylcellulose,and hydroxypropylcellulose; synthetic water-soluble cellulose-basedlamina formers such as methyl cellulose and its hydroxyalkylmethylcellulose cellulose derivatives, such one of the following groupincluding hydroxyethyl methylcellulose, hydroxypropyl methylcellulose,and hydroxybutyl methylcellulose; other cellulose polymers such assodium carboxymethylcellulose; and other materials known to those ofordinary skill in the art. Other lamina forming materials that can beused for this purpose include poly(vinylpyrrolidone), polyvinylalcohol,polyethylene oxide, a blend of gelatin and polyvinyl-pyrrolidone,gelatin, glucose, saccharides, povidone, copovidone,poly(vinylpyrrolidone)-poly(vinyl acetate) copolymer.

Delaying the release of vagal neuromodulators in the stomach may beachieved by the use of floating particles with lower density thangastric fluid. In one possible embodiment, floating particles resultfrom the release of carbon dioxide within ethylcellulose-coated sodiumbicarbonate beads upon contact with gastric fluids. The release ofcarbon dioxide from the ethylcellulose-coated sodium bicarbonate corecauses particle buoyancy, thereby delaying the release of vagalneuromodulators from the particles.

Other delayed gastric-emptying approaches may be used in order to delaythe release of vagal neuromodulators in the stomach. These include theuse of indigestible polymers or fatty acid salts that change themotility pattern of the stomach to a fed state, thereby decreasing thegastric emptying rate and permitting considerable prolongation of drugrelease.

In certain conditions, it may be desirable to prolong the retention timeof vagal neuromodulator(s) in the stomach by using forms that unfoldrapidly within the stomach to a size that resists gastric emptying. Suchsystems retain their integrity for an extended period of time and arenot emptied from the stomach until breakdown into small pieces occurs. Across-shaped device made of erodible polymer and loaded with drug whichis folded and inserted into a hard gelatin capsule has been used inother applications. Following oral administration, the gelatin shelldisintegrates and the folded device opens out. With a size of 1.6-5 cm,it cannot pass from the stomach through the pylorus until the polymer issufficiently eroded.

Prolonging the retention time of vagal neuromodulators in the stomachmay be achieved by using a hydrophilic erodible polymer system such asPolyethylene oxide (Polyox) and Hydroxypropyl-methylcellulose (HPMC) ata size convenient for administration to humans. Upon imbibing fluid, thesystem rapidly swells to a size that will encourage prolonged gastricretention, allowing sustained delivery of the contained drug toabsorption sites in the upper gastrointestinal tract. Since thesesystems are made of an erodible, hydrophilic polymer(s), they readilyerode over a reasonable time and pass out of the stomach. The timeperiod of expansion is such that this will not occur in the esophagusand, if the system passes into the intestine in a partially swollenstate, the erodibility and elastic nature of the hydrated polymer willeliminate the chance of intestinal obstruction by the device.

In one embodiment, the pharmaceutical composition of the presentinvention is formulated as a single dosage form comprising multiplebeads contained in hard or soft gelatin capsules. The capsules contain amixed population of beads selected from: beads containing ImmediateRelease (IR) of CNS active agent, or beads comprised of the CNS activeagent coated with time-dependent release polymer, beads comprised ofcalcium carbonate, beads comprised of ethylcellulose, sodium bicarbonatebeads coated with vagal neuromodulator(s) and calcium carbonate andhydroxypropyl methylcellulose. The cellulose-based polymer in thecomposition permits the vagal neuromodulator beads to float, thusdelaying the release of vagal neuromodulators from the beads. The rateof vagal neuromodulator release is determined by the thickness and theerosion rate of the hydroxypropyl methylcellulose.

In another embodiment, the gelatin capsules contain mixed population ofbeads selected from: beads comprised of IR-coated CNS active agent orbeads comprised of CNS active agent coated with time-dependent releasecoating, beads comprising calcium carbonate and beads comprisingalginate coated with vagal neuromodulator(s), calcium carbonate andhydroxypropyl methylcellulose.

In yet another embodiment, the gelatin capsules contain mixed populationof beads selected from: beads comprised of IR-coated or non-coated CNSactive agent, or beads comprised of CNS active agent coated withtime-dependent release polymer, beads comprised of one type of vagalneuromodulators (such as GUA) and particles in the form of mini-tabscomprised of a second type of vagal neuromodulator (such as PHE), otherexcipients and hydroxypropyl methylcellulose.

In still another embodiment, the pharmaceutical compositions of thepresent invention are formulated as press-coat or double-layered tabletscomprised of IR CNS active agent in one layer, with a second layercomprised of the vagal neuromodulators PHE and GUA, and hydroxypropylmethylcellulose.

In a further embodiment, the pharmaceutical compositions of the presentinvention are formulated in a triple-layered table comprising vagalneuromodulators and CNS active agent granules mixed into multi-componentformulations. The layers of the formulations are released from thetablet at different rates. As a non-limiting example, the tabletcomprises a first layer of baclofen granules (immediate release), asecond layer of pseudoephedrine granules (immediate release), and athird, controlled release layer of GUA granules (delayed/slow release).

The pharmaceutical composition of the present invention may beformulated as a two layer non-aqueous semi-solid packed into hardgelatin capsules in which the CNS active agent is solubilized in a lipidbase (non-aqueous, quick release). The lipid base is liquid above roomtemperature but forms a semi-solid upon cooling, thus allowing itsencapsulation. A lipid soluble mucomodulator (such as GUA), or a finesuspension of sodium bicarbonate, or sorbitol, or PHE, or combination ofat least two thereof may be included as well.

In one embodiment, the single dosage form of the pharmaceutical iscomprised of non-coated CNS active agent particles or immediate release(IR)-coated particles. The absorption of IR coated, or non-coated CNSactive agents in the duodenum and upper jejunum or ileum is faster thanthe absorption of coated CNS active agents. Therefore, the use ofnon-coated CNS active agents in the composition permits a more precisesynchronization between the biological activity of vagal neuromodulatorsand the time in which the CNS active agent is active, without the needfor delayed neuromodulator release. Thus, the pharmaceuticalcompositions of the present invention are formulated as double-layeredtablets, press-coat tablets, effervescent tablets or suspension tabletsand are comprised of NMs, such as osmoreceptor stimulator (potassiumchloride), or/and pH modulator, or secretagogues (succinic acid,caffeine, or pilocarpine) non-coated, or IR-coated particles of CNSactive agents and one or more excipients.

The active ingredients of the pharmaceutical composition of the presentinvention may be formulated in multiple oral dosage forms in which oneor more mechanoreceptor stimulators are administered in a separatedosage form but in conjunction with the CNS active agent. For example,the one or more mechanoreceptor stimulators may be formulated as an oralsuspension or as a solid dosage form (such as capsules, tablets,suspension tablets, or effervescent tablets), while the CNS agent may beformulated in a separate solid dosage form, such as IR-coated beads ortime-dependent release beads contained in capsules or tablets.

In another embodiment, the vagal neuromodulators in the separate dosageform are formulated as suspension tablet, effervescent tablet, chewabletablet or powder for suspension for compliance of neuropsychotic oraddicted patients. However, tablets or capsules are also possible as adosage form for the buffering agents.

When using multiple oral dosage forms, vagal neuromodulator(s) can beadministered before, simultaneously, or after the CNS active agent. Insequential administration, there may be some substantial delay (e.g.,minutes or even few hours) between the administration of the vagalneuromodulator(s) and the CNS active agent, as long as the NMs exert aphysiological effect when the CNS active agent becomes active. In oneembodiment, the CNS active agent administered is in a time-dependentrelease form, preferably before the vagal neuromodulator'sadministration in order to ensure that the CNS active agent (alreadyabsorbed into the blood from the intestines) will be available formodulation of vagal afferent or efferent receptors while theneuromodulators are active in the stomach.

The active ingredients of the pharmaceutical composition may beincorporated within inert pharmaceutically acceptable beads. In thiscase, the CNS active agent and vagal neuromodulators may be mixed withadditional ingredients prior to being coated onto the beads. Ingredientsinclude binders, surfactants, fillers, disintegrating agents, alkalineadditives or other pharmaceutically acceptable ingredients, alone or inmixtures. Binders include, for example, celluloses such as hydroxypropylmethylcellulose, hydroxypropyl cellulose and carboxymethyl-cellulosesodium, polyvinyl pyrrolidone, sugars, starches and otherpharmaceutically acceptable substances with cohesive properties.Suitable surfactants include pharmaceutically acceptable non-ionic orionic surfactants, such as sodium lauryl sulfate.

The particles may be formed into a packed mass for ingestion byconventional techniques. Particles may be encapsulated as a “hard-filledcapsule” using known encapsulating procedures and materials. Theencapsulating material should be highly soluble in gastric fluid so thatthe particles are rapidly dispersed in the stomach after the capsule isingested.

In another embodiment, the active ingredients of the present inventionare packaged in compressed tablets. The term “compressed tablet”generally refers to a plain, uncoated tablet for oral ingestion,prepared by a single compression or by pre-compaction tapping followedby a final compression. Such solid forms can be manufactured usingmethods well known in the art. Tablet forms can include, for example,one or more of lactose, mannitol, cornstarch, potato starch,microcrystalline cellulose, acacia, gelatin, colloidal silicon dioxide,croscarmellose sodium, talc, magnesium stearate, stearic acid, and otherexcipients, colorants, diluents, buffering agents, moistening agents,preservatives, flavoring agents, and pharmaceutically compatiblecarriers. The manufacturing processes may employ one, or a combinationof, four established methods: (1) dry mixing; (2) direct compression;(3) milling; and (4) non-aqueous granulation. Such tablets may alsocomprise film coatings, which preferably dissolve upon oral ingestion orupon contact with diluents.

In another embodiment, the pharmaceutical compositions of the presentinvention are formulated in compressed forms, such as suspension tabletsand effervescent tablets, such that an aqueous form of thepharmaceutical composition is produced upon reaction with water or otherdiluents upon oral administration. These forms are particularly usefulfor medicating children and the elderly and others in a way that is muchmore acceptable than swallowing or chewing a tablet. The presentpharmaceutical composition tablets or other solid dosage formsdisintegrate the pH modulator with minimal shaking or agitation.

The term “suspension tablets” as used herein refers to compressedtablets which rapidly disintegrate after they are placed in water, andare readily dispersible to form a suspension containing a precise dosageof the CNS active agent, PHE and GUA. In one embodiment, the suspensiontablets may be comprised of CNS active agent at about ½ to 1/10 of theconventionally accepted effective dosage (for example less 4 mg ofmorphine), 10-200 mg PHE (Phenylepherine hydrochloride) and about100-1200 mg of GUA (Guaifenesin). To achieve rapid disintegration of thetablet, a disintegrant such as Croscarmellose sodium may be added to theformulation. The disintegrant may be blended in compressed tabletformulations either alone or in combination with microcrystallinecellulose (Avicel®). Microcrystalline cellulose, alone or co-processedwith other ingredients, is well known for its ability to improvecompressibility of difficult to compress tablet materials.

The suspension tablet composition may, in addition to the ingredientsdescribed above, contain other ingredients often used in pharmaceuticaltablets, including flavoring agents, sweetening agents, flow aids,lubricants or other common tablet adjuvants, as will be apparent tothose skilled in the art. Other disintegrants, such as crospividone andsodium starch glycolate may be employed, although croscarmellose sodiumis preferred.

In another embodiment, the pharmaceutical composition of the presentinvention may comprise a powder, preferably effervescent, for oralsuspension presented as a sachet. The powder may comprise differentagents or dosage forms, allowing for varying rates of release. As anon-limiting example, the powder comprises GHB granules (immediaterelease), pseudoephedrine granules (immediate release), andpolymer-coated GUA granules (delayed release).

In addition to the above ingredients, the oral dosage forms describedabove may also contain suitable quantities of other materials, e.g.diluents, lubricants, binders, granulating aids, colorants, flavorantsand glidants that are conventional in the pharmaceutical art and willvary to provide the desired effect to the desired formulation.

In another embodiment, the pharmaceutical composition of the presentinvention may comprise a kit. The kit comprises directions for theadministration of the separate components. The kit form may be desirablewhen the separate components are preferably administered in differentoral dosage forms or at different dosage intervals, or when titration ofthe individual components of the combination is desired by theprescribing physician. For example, the neuromodulator or combination ofneuromodulators may be provided in one dosage form and the CNS activeagent may be provided in a separate dosage form. In this case, theneuromodulator composition is administered in conjunction with the CNSactive agent so that there is at least some chronological overlap intheir physiological activity. The CNS active agent and neuromodulatorcan be administered simultaneously and/or sequentially. An example ofthe kit is a blister pack. Blister packs are well known in the packagingindustry and are being widely used for the packaging of pharmaceuticalunit dosage forms (tablets, capsules, and the like). Blister packscontain a sheet of relatively stiff material covered with a foil of apreferably transparent plastic material. Tablets or capsules are placedin individual packets formed in the plastic foil and sealed. Tablets orcapsules can be removed from the blister pack by manually applyingpressure on a desired individual packet to open it and remove the tableor capsule.

Instructions, including a memory aid, can be provided with or on the kit(e.g., aid is a calendar printed on the card as follows “First Week,Monday, Tuesday, . . . etc. * Second Week, Monday, Tuesday, . . . ”etc.) A “daily dose” can be a single tablet or capsule or severaltablets or capsules to be taken on a given day. Also, a daily dose of aneuromodulator composition can consist of one tablet or capsule, while adaily dose of the CNS active agent can consist of several tablets orcapsules and vice versa. The memory aid should reflect this.

In another embodiment, the kit comprises a blister pack that containstwo neuromodulators at the single form and two doses of the CNS activeagent, with one dose for morning/day administration and another fornight time administration. In this embodiment a morning/day dose isadministered in conjunction with neuromodulators to reduce unwantedsedation side effects during day activity, or formulated in a singlefixed combination form with neuromodulators. The night time dose of theCNS active agent is in a separate form without neuromodulators and isused partially as a sedative to improve sleep. This is especially usefulfor benzodiazepines and other GABA-acting CNS agents when the CNS agenthas a dual therapeutic purpose—one of which is sedation, and is theother is anxiolytic (wherein sedation-related effects are undesirablethroughout the day).

In a further embodiment, two different CNS agents are incorporated intothe kit, one is used in conjunction with neuromodulators in a single orseparate form and the second has a different therapeutic mode of actionwhich may be synergistic or complementary to the first CNS agent. Forexample, the first CNS agent, a benzodiazepine for example, may becombined with neuromudulators as an adjunctive to reduce thesedation-related effects associated with benzodiazepine usage. Inaddition, this first CNS agent may be used with SSRI in a separate formto improve anxiolytic activity. Thus, the kit scheme is easily adaptableto a variety of situations, including day time and night timeadministration. (FIGS. 1-3)

In a further embodiment, the kit comprises a single piece packaged in adouble dual reservoir and separated by a layer that does not require thedosage forms to be in contact before opening by the user or caregiver.(FIG. 4).

In another preferred embodiment, the kit comprises powder, preferablyeffervescent dosage forms, separated by a layer that allows allreservoirs of the blister to be opened simultaneously and allows thepatient to dilute the powder dosage forms in a glass of liquid foradministration.

The pharmaceutical composition kit form reduces the side-effect ofhypotension induce by the CNS active agents (i.e. opiate, barbiturate,benzodiazepine, sodium oxybate, atypical neuroleptics). The kitcomprises: (a) CNS active agent in pharmaceutical compatible excipient;(b) hypertensive agent in pharmaceutical compatible excipient; and (c)instructions (e.g. an insert) describing timing/schedule ofadministration of (a) and (b) components.

In another embodiment (a) CNS active agent(s) are selected from thefollowing groups: benzodiazepines, atypical neuroleptics, barbiturates,sodium oxybate, opiates, or combinations thereof; (b) hypertensive agentis a selective alpha ADR receptor agonist Phenylephrine (vagal afferentneuromodulator); (c) and instructions for delay of about 15-30 minutesbetween administration of (a) and (b). In another embodiment, CNScentral nervous system stimulants, for example caffeine or dexedrine canbe included. Alternatively, pseudoephedrine, as a neuromodulator(NM)-agent may be added to the kit. (PSE) exhibits dual action: (i) notselective antagonist of ADR receptors, including vagal afferent chemo-and mechano-receptors; and (ii) CNS stimulant. In another embodiment,effective of CNS active agent in the kit may be at least two times lowerthan the same CNS active agent when used as a stand alone medication.Instructions describing the sequence of use of kit ingredients are alsoprovided.

Having described the formulation of the pharmaceutical composition, thereduced dosages of CNS active agents as part of the pharmaceuticalcomposition of the present invention, are set forth below. This listshould not be construed as a conclusive list but as a guideline for anyof the desired combinations of the present invention.

-   -   Olanzapine: from ˜0.25 to ˜100 mg, once/day; preferred, from        ˜0.2 to ˜30 mg, once/day; preferrably from ˜0.1 to ˜25 mg        once/day,    -   Clozapine: from ˜12.5 to ˜900 mg daily; preferred, from ˜4 to        ˜450 mg daily;    -   Risperidone: from ˜0.25 to ˜16 mg daily; preferred from ˜0.2-8        mg daily;    -   Sertindole: from ˜0.0001 to ˜1.0 mg/kg daily, preferred 0.0001        to ˜0.5 mg/kg daily;    -   Quetiapine: from ˜1.0 to ˜40 mg/kg given once daily or in        divided doses; preferred 0.5 to ˜30 mg/kg daily);    -   Risperidone: from ˜0.25 to ˜16 mg daily; preferred from ˜0.1-8        mg daily;    -   Asenapine: from ˜0.005 to ˜60 mg total per day, given as a        single dose or 25 in divided doses; preferred from ˜0.0025-30 mg        daily,    -   Carbamezepine: from ˜200 to ˜1200 mg/day; preferably ˜100-400        mg/day,    -   Valproic Acid: from ˜250 to ˜2500 mg/day, preferably ˜100 ˜1000        mg/day,    -   Lamotrigine: from ˜50 to ˜600 mg/day in 1 to 2 doses; preferably        ˜25 to ˜400 mg; most preferably ˜200 mg;    -   Gabapentin: from ˜300 to ˜3600 mg/day in 2 to 3 divided doses;        preferably 300 to ˜1800 mg/day; most preferably ˜900 mg/day;    -   Tiagabine: from ˜2 to ˜56 mg/day in 2 to 4 divided doses;        preferably ˜1 to ˜30 mg/day, most preferably ˜20 mg/day;    -   Topiramate: from ˜200 to ˜600 mg/day divided in 2 doses; most        preferably 35 to ˜400 mg/day;    -   Kionopin (Clonazepam): from 0.25 to 20 mg, preferably ˜0.1 to 10        mg;    -   Tranxene (Clorazepate): from 3.75 to 60 mg, preferably ˜1 to 30        mg;    -   Valium (Diazepam): from 1 to 40 mg, preferably ˜0.5 to 20 mg;    -   Xanax (Aiprazolam): from 0.25 to 4 mg, preferably ˜0.1 to 2 mg;    -   Gabitrii (Tiagabine): from 4 to 56 mg, preferably ˜2 to 30 mg;    -   Neurontin (Gabapentin): from 100 to 2400 mg, preferably ˜50 to        1000 mg;    -   Dilantin (Phenyloin): from 50 to 1200 mg, preferably ˜25 to 600        mg;    -   Carbatrol Capsules ER (Carbamazepine): from 200 to 1200 mg,        preferably-100 to 600 mg;    -   Depakote (Vaiproic acid): from 250 to 2000 preferably ˜150 to        1000 mg;    -   Felbatol (Felbamate): from 1200 to 3600 mg preferably ˜600 to        1200 mg;    -   Keppra (Levetiracetam): Minimum 1000 to 3000 mg, preferably        ˜1000 to 3000 mg;    -   Tegretol (Carbamazepine): from 200 to 1200 mg, preferably ˜100        to 600 mg;    -   Topamax (Topiramate): from 25 to 400 mg, preferably ˜15 to 200        mg;    -   Celontin (Methoximide): from 150 to 1200 mg, preferably ˜80 to        600 mg;    -   Trileptal (Oxcarbazepine): from 300 to 2400 mg, preferably ˜150        to 1200 mg;    -   Zonegran (Zonisamide): from 100 to 600 mg, preferably ˜50 to 300        mg;    -   Lamictal (Lamotrigine): from 200 to 400 mg, preferably ˜100 to        200 mg;    -   Zarontin Capsules (Ethosuximide): from 250 to 1500 mg,        preferably ˜150 to 750 mg;

The following examples of formulations of the pharmaceutical compositionof the present invention are presented in order to more fully illustratecertain embodiments of the invention. However, they should in no way beconstrued as limiting the broad scope of the invention. After becomingfamiliar with the teachings herein, one of ordinary skill in the art canreadily devise many variations and modifications of the embodimentsdisclosed herein without departing from the scope of the invention. Itwill be appreciated by a person or ordinary skill in the art that thepresent invention is not limited by what has been particularly shown anddescribed below.

Hard Gelatin Capsules

Hard gelatin capsules may contain a mixed granules population ofPhenylephrine tannate (PHE) and benzodiazepine (BDZ). PHE granules arein IR or delayed release formulation; BDZ is formulated astime-dependent release coating (immediate or slow release). Granules maybe packed into a hard gelatin capsule in an amount corresponding to 1 mgBDZ and 30 mg PHE per capsule. The IR layer comprises: 40 mg oftime-dependent release coated (HPMC); BDZ granules; and diluent. Thedelayed release layer comprises: 100 mg of granules 30 mg PHE; granules(HPMC coated); and diluent. For the delayed release of PHE formulation,a PHE solution is sprayed on inert beads in a fluid bed apparatus. Afterdrying, the PHE beads are further coated with hydroxypropylmethylcellulose (HPMC) to form the final granules. The rate of PHErelease is determined by the thickness and erosion rate of the HPMClayer. PHE is aimed to be released from the coated beads 10-20 minfollowing administration.

Powder for Oral Suspension

Examples of powder for oral suspension or effervescent (sache)formulation are comprised of vagal nerve afferent neuromodulators(PHE/GUA) and vagal nerve efferent neuromodulators (succinic acid-SAor/and derivative of SA/or and/or caffeine) granules mixed in themulti-components formulations. The PHE/GUA/SA granules are coated withthink HPMC layer IR. They are added to a glass of water, for example,just prior to administration of the BDZ granules (IR).

Double Layer Tablet

Neuromodulators (PHE/GUA) and CNS active agent (BDZ) granules mixed inthe multi-components formulations. The double layer tablet formulationcomprises PHE/GUA granules are coated with thin HPMC layer (delayedrelease ˜15 min) and form the top layer. BDZ granules (immediate or slowrelease).

Regimen for Psychotic Disorders

The pharmaceutical composition comprises respective amounts of olazepineand the neuromodulator composition to be delivered on a daily basisbetween ˜1 mg to ˜160 mg olazepine and between ˜1 to ˜1000 mg of theneuromodulator composition. The composition is administered to a patientfor the treatment of schizophrenia on a once, twice, thrice, or fourtimes per day basis. Controlled release delivery systems are designed toallow pharmacodynamic synchronization between CNS active agents andvagal neuromodulators without interfering with pharmacokineticparameters (see TABLE 5 below) and metabolism of CNS active agents. Allof the data in TABLE 5 came from Martindale. Synchronization of the CNSactive agent and the vagal neuromodulators of the present invention havebeen described herein above.

TABLE 5 Pharmacokinetic parameters of various CNS active agents.Selected neuromodulators Epinephrine CNS Active Agent (adrenaline)Phenylephrine Pseudoephedrine Mitodrin bioactivity Tmax Tmax Tmax TmaxTmax Olanzapine 40% 5-8 h 15 min 10-15 min 0.5-1 h 15-30 min Clozapine50% 2.5 h Lorazepam 90% 2 h Alprazolam 55% 1-2 h Clonazepam 90% 4 hDiazepam 97% 0.5-1.5 h Phenobarbital 2 h Vigabatrin (GVG) 0.4-1 h GHB0.5-2 h

In one embodiment, the sequence of the CNS active agent andPhenylephrine, or other Neuromodulator(s) is delayed at least 15-30minutes so that Phenylephrine is administered after the CNS active agentto address hypertension while reducing the conventionally acceptedeffective dose of the CNS active agent by at least twice. In addition,the insertion of guidance timing which would be measurable or atimer-signaling device is also possible.

In another embodiment, at least two dosage form compartments may bepresent in a dosage form unit. CNS active agents preferably will beincorporated in an immediate release compartment, but may also beincorporated in a sustained release compartment or enteric coatedrelease (designed for immediate release in the intestine) compartment.Neuromodulator (NM) cocktails may be contained in the delayed layercompartments. The release of the (NM) contained in delayed-release(second) dosage form compartment initiated (meaning of “form compartmentinitiated” not clear) at least one hour after the first CNS active agentcontained dosage form initiates release, with the initiation of therelease generally occurring no more than six hours after initiation ofrelease of CNS active agent from the first dosage form.

In another embodiment the first dosage form produces a Cmaxfor the CNSagent released from the immediate release compartment withinapproximately 0.2 to 6 hours after initiation of release, with theneuromodulators released from delayed dosage form in no more thanapproximately 0.5-4 hours after initiation of the release from the firstdosage form.

In another embodiment, the first dosage form initiates release of NMagent(s) at a time later as compared to when the CNS active agents wouldbe released from an immediate release dosage form. For example, thefirst dosage form compartment would initiate release within 1 to fourhours after administration of the product.

An Immediate Release Compartment

The immediate release portion of this system can be a mixture ofingredients that breaks down quickly after administration to release theCNS active agent, and neuromodulator, such as PHE. This can take theform of either a discrete pellet or granule that is mixed in with, orcompressed with, the other three components.

The materials to be added to the CNS active agent (for example,flunitrazepam, diazepam, clozapine or olanzapine, or otherantidepressant, anti-psychotic or anxiolytic or other CNS active agent)for the immediate release embodiments include microcrystallinecellulose, corn starch, pregelatinized starch, potato starch, ricestarch, sodium carboxymethyl starch, hydroxypropylcellulose,hydroxypropylmethylcellulose, hydroxyethylcellulose, ethylcellulose,chitosan, hydroxychitosan, hydroxymethylatedchitosan, cross-linkedchitosan, cross-linked hydroxymethyl chitosan, maltodextrin, mannitol,sorbitol, dextrose, maltose, fructose, glucose, levulose, sucrose,polyvinylpyrrolidone (PVP), acrylic acid derivatives (Carbopol,Eudragit, etc.), polyethylene glycols, such as low molecular weight PEGs(PEG2000 10000) and high molecular weight PEGs (Polyox) with molecularweights above 20,000 daltons.

It may be useful to have these materials present in the range of 1.0 to60% (W/W). In addition, it may be useful to have other ingredients inthis system to aid in the dissolution of the drug, or the breakdown ofthe component after ingestion or administration. These ingredients canbe surfactants, such as sodium lauryl sulfate, sodium monoglycerate,sorbitan monooleate, sorbitan monooleate, polyoxyethylene sorbitanmonooleate, glyceryl monostearate, glyceryl monooleate, glycerylmonobutyrate, one of the non-ionic surfactants such as the Pluronic lineof surfactants, or any other material with surface active properties, orany combination of the above. These materials may be present in the rateof 0.05 to 15% (W/W).

Delayed Release Component

In this embodiment, the components in this composition are the sameimmediate release embodiment, but with additional polymers integratedinto the composition or as coatings over the pellet or granule.

Materials that can be used to obtain a delay in release suitable forthis embodiment of the invention include polyethylene glycol (PEG) withmolecular weight above 4,000 daltons (Carbowax, Polyox), waxes such aswhite wax or bees wax, paraffin, acrylic acid derivatives (Eudragit),propylene glycol, and ethylcellulose. These materials may be present inthe preferable range of 0.5-25% (W/W) of this component.

The pH Sensitive (Enteric) Release Component

In this embodiment, the components may be the same as the immediaterelease component, but with additional polymers integrated into thecomposition, or as coatings over the pellet or granule. The materialsuseful for this purpose include cellulose acetate pthalate, Eudragit L,and other pthalate salts of cellulose derivatives, present inconcentrations from about 4-20% (W/W).

The pharmaceutical composition may be formulated by mixing theingredients in a suitable pharmaceutical mixer or granulator such as aplanetary mixer, high-shear granulator, fluid bed granulator, orextruder, in the presence of water or other solvent, or in a hot meltprocess. If water or other solvent was used, dry the blend in a suitablepharmaceutical drier, such as a vacuum oven or forced-air oven. Theproduct is then cooled and may be sieved or granulated and compressedusing a suitable tablet press, such as a rotary tablet press.

The following are examples of delayed release compartments containingthe neuromodulator of the present invention.

Example A

PHE-phenylephrine 65% (W/W); Microcrystalline cellulose 20%; Polyox7.5%; and Croscarmellose sodium 7.5%.

Example B

Epi-epinephrine 55% (W/W); Microcrystalline cellulose 25%; Polyox 10%;and Glyceryl monooleate 10%.

Example C

PSE-pseudoephedrine 75% (W/W); Polyox 10%; Hydroxypropylcellulose 5%;and Croscarmellose sodium 10%.

Example D (W/W)

PHE 35%; Gua (Guaifenesin) 30%; Microcrystalline cellulose 20%; Polyox7.5%; and Croscarmellose sodium 7.5%

Example E (W/W)

PHE 35%; NAC (n-acetylcystein) 30%; Microcrystalline cellulose 25%;Polyox 10%; and Glyceryl monooleate 10%.

Example F (W/W)

PHE50%; Ole (sodium oleate)−25%; Polyox 10%; Hydroxypropylcellulose 5%;and Croscarmellose sodium 10%.

Example G (W/W)

PHE 35%; SA (succinic acid)-30%; Microcrystalline cellulose 20%; Polyox7.5%; and Croscarmellose sodium 7.5%.

Example H (W/W)

PHE 55%; Microcrystalline cellulose 25%; Polyox 10%; Glyceryl monooleate10%.

Example I (W/W)

PSE 75%; Polyox 10%; Hydroxypropylcellulose 5%; and Croscarmellosesodium 10%.

Example J (W/W)

PHE 65%; icrocrystalline cellulose 20%; Polyox 7.5%; and Croscarmellosesodium 7.5%.

Example K (W/W)

PSE 25%; GUA 30%; Microcrystalline cellulose 25%; Polyox 10%; andGlyceryl monooleate 10%.

Sustained Release CNS Active Agent Containing Compartment

In another embodiment, the components are the same as the immediaterelease embodiment (as above), but with additional polymers integratedinto the composition, or as coatings over the pellet or granule.Materials useful for this purpose include ethylcellulose,hydroxypropylmethylcellulose, hydroxypropylcellulose,hydroxyethylcellulose, carboxymethylcellulose, methylcellulose,nitrocellulose, Eudragit R, and Eudragit R L, Carbopol, or polyethyleneglycols with molecular weights in excess of 8,000 daltons, which may bepresent in concentrations from 4-20% (W/W).

As indicated above, the CNS active agent-NM cocktail pharmaceuticalcomposition of the present invention may comprise of discrete pellets orparticles contained in the capsule, or particles embedded in a tablet orsuspended in a liquid suspension.

Neuromodulators (NM)—Containing Delayed Pellet Formulations

Phenylephrine (PHE) is one neuromodulator of the present invention. PHEexamples to achieve various delays of PHE described release (as providedby various coating procefures of PHE pellets) are described.

Encapsulation of the PHE Pellets:

Pellets are filled into hard gelatin capsules at a ratio of33.4%:66.6%:CNS agent granules and PHE Pellets respectively.

The capsule is filled with the three different pellets to achieve thedesired dose.

Sustained Release Component for Incorporation for GUA:

In another embodiment, the components are the same as the immediaterelease component, but with additional polymers integrated into thecomposition, or as coatings over the pellet or granule. Materials usefulfor this purpose include ethylcellulose, hydroxyl-propylmethylcellulose,hydroxypropylcellulose, hydroxyl-ethylcellulose, carboxymethylcellulose,methylcellulose, nitrocellulose, Eudragit R, and Eudragit R L, Carbopol,or polyethylene glycols with molecular weights in excess of 8,000daltons, which may be present in concentrations from 4-20% (W/W). TheCNS active agent-NM cocktail (including GUA) of the present inventionmay take in the form of discrete pellets or particles contained in thecapsule, or particles embedded in a tablet or suspended in a liquidsuspension.

Examples for Preparation Procedures and Delayed Pellet Formulations:

The following examples demonstrate possibilities to reach various delayof release of GUA as provided by various coating procedures of GUApellets.

Example—The composition of excipients for preparation of GUA-500 mgpellets provided below.

-   -   Avicel PH 101-6.0%    -   Polyoxyl −35%    -   Castor Oil −1.0%. Hydroxypropyl methylcellulose and Cremaphor EL        were added as a 2.9% w/w aqueous solution during wet massing.    -   Hydroxypropyl methylcellulose, NF −1.0%    -   Purified Water (total 100%)—Removed during processing

Composition of CNS Agent-PVN Tablets Component Percentage:

-   -   Silicified microcrystalline cellulose 21.6%    -   Lactose monohydrate 13.0%    -   Povidone 5.0%    -   CNS agent granulated (non-coated)-1.3%    -   Phe (non-coated)-17%    -   Coated Pellets of GUA-36.6%    -   Croscarmellose sodium 5.0%    -   Magnesium stearate 0.5%

Blending Procedure:

-   -   Blend the silicified microcrystalline cellulose, lactose        monohydrate, povidone, colloidal silicon dioxide CNS agent        granules and Phe coated pellets for 15 minutes in a tumble        blender.    -   Add the magnesium stearate to the blender, and blend for 5        minutes.-Compress the blend on a rotary tablet press.    -   Adjusted the fill weight to achieve the desired dose.

Encapsulation of the PHE Pellets:

Pellets are filled into hard gelatin capsules at a ratio of33.4%:66.6%:CNS agent granules and Phe pellets respectively. The capsuleis filled with the three different pellets to achieve the desired dose.

Having described the ingredients and formulations of embodiments of thepharmaceutical composition of the present invention, method(s) oftreating humans will now be described. of advantage to provide a CNSactive agent (for example, a benzodiazepine) combined with at least oneneuromodulator, in a dosage form that delivers the required therapeuticamount of the drug in vivo, and that renders the CNS active agentbioavailable in a constant manner.

The method of administering the pharmaceutical composition of thepresent invention may be used to treat a variety of diseases, illnessesand conditions for which the CNS active agents of the present inventionmight be prescribed when used alone, or in combination with othertherapies. Categories of these diseases, illnesses and conditionsinclude depression; anxiety, psychotic, delusional, mood and personalitydisorders; memory disorders and dementia; phobias; sexual dysfunction;chemical dependencies to addictive CNS active agents, including alcohol;eating disorders; alcohol addition; Parkinson's diseases; endocrinedisorders; vasospasm; gastrointestinal tract disorders; cancer;headache; osteoporosis or frailty associated with aging or obesity; andcardiovascular or heart related disease. Using the pharmaceuticalcomposition of the present invention according to embodiments of methodsherein may aid in accelerating bone fracture repair; attenuating proteincatabolic response after a major operation; reducing cachexia andprotein loss due to chronic illness; accelerating wound healing andaccelerating the recovery of burn patients or of patients havingundergone major surgery.

According to one embodiment of the method of the present invention, amethod for reducing depending of an addictive CNS active agent comprisesadministering to a patient between about 20 to about 80 percent of theconventionally accepted effective dosage of the addictive CNS activeagent; administering to the patient at least one mechanoreceptorstimulator and at least one chemoreceptor stimulator, themechanoreceptor stimulator, the mechanoreceptor stimulator and thechemoreceptor stimulator being administered for synchronization of theTmax of the addictive CNS active agent and the Tmax of themechanoreceptor stimulator. The delay time in administration as afunction of Tmax of the mechanoreceptor stimulator (NM) and the CNSactive agent are described in more detail above.

In another embodiment of the present invention, the method foradministering the pharmaceutical composition of the present invention(CNS active agent, plus mechanoreceptor stimulator and another vagalneuromodulator in amounts sufficient to reduce CNS active agentside-effect(s)) comprises co-administering the CNS active agent and themechanoreceptor stimulator, and the vagal neuromodulator sequentially orin time-released form thereby ameliorating CNS active agent side-effectswithout reducing the conventionally accepted effective dosage of the CNSactive agent. In yet another embodiment of the method for administeringthe pharmaceutical composition described immediately above, the methodcomprises co-administering the CNS active agent and the mechanoreceptorstimulator at a level sufficient to maintain the pharmacokineticeffectiveness of the CNS active agent while reducing associatedside-effects.

Yet another method comprises the step of administering to a subject atherapeutically effective amount of benzodiazepine-neuromodulatorformulation of the present invention. In one embodiment, thebenzodiazepine-neuromodulator formulation is an injectable. In anotherembodiment, the benzodiazepine-neuromodulator formulation is an aerosolformulation. The pharmaceutical composition of the invention does notrequire a high CNS active agent (benzodiazepine) concentration that maylead to dose-dependent side-effects. Using lower benzodiazepine dosageswill allow patient recovery and reduced inpatient care.

A general protocol for oral administration comprises IR formulation ofbenzodiazepine followed by a combination of vagostimulators or otherneuromodulator(s) in IR formulation (preferably as an effervescentformulation) with a delay of between administrating of benzodiazepineand neuromodulator cocktail at least 50% of a known Tmax ofbenzodiazepine in blood in order to obtain optimal synchronizationbetween onset of neuromodulation and availability of benzodiazepine incirculation and CNS target site.

The methods of this invention also encompass treating the diseases orconditions described herein by the co-administration of two separatepharmaceutical compositions and by administrating to a patient singledosage form as described above. The methods and pharmaceuticalcompositions of the invention are directed to the treatment andprevention of stress conditions and nervous dysfunctions such asconvulsions, seizure, muscle stiffness, psychotic disorders, depression,anxiety-related disorders, substance addiction, memory impairment,neuro-gastroenterological disorders and pain.

The present invention reduces or prevents the side-effects ofdepression, dizziness, drowsiness, lethargy, weakness in theextremities, difficulty in being mobile, and orthostatic hypotension andother blood pressure effects associated with therapeutic CNS actingagents without compromising the positive clinical effects of those sametherapeutic agents. By reducing or preventing these side-effects, thepresent invention also decreases the risk of injury to patients andliability to healthcare personnel treating such patient populations.Further, by reducing the risk to patient and health personnel alike, thepresent invention increases the opportunity for out-patient treatmentsettings, which in turn decreases overall healthcare costs. Finally, byminimizing side-effects to patients with the present invention,incidences of relapse are reduced or prevented.

TABLE 6 Design of neuromodulator release for various CNS drugs. CNSActive Agent GUA release delay* Tmax Half-life Anti-parkinsonianApomorphine 15 min (fast, but injection) 1 h Bromocriptine 15 min 1-2 h7 h Cabergoline 10 min 0.5-4 h 63-69 h Lisuride 10 min 1.1-1.3 h 2 hRopinirole 15 min 1-2 h 6 h Pramipexole 10 min 1 h 8 h Benztropine 15min 1-2 h 36 h Biperiden 10 min 1.5 h 18-24 h Anti-painMeperidine(Pethidine) 45 min IV, several min 3-5 h oral, up to 1.5 hMethadone 15 min 1-7.5 h 24-36 h Flunarizine 10 min 1 h 19 daysMetoprolol 25 min (fast) up to 1 h 3-7 h Methotrimeprazine 20 min 1-4 h20 h Robaxin 10 min 0.5-1 h 1.14-1.24 h Flexeril 15 min 1 h 1-3 daysBaclofen 15 min 0.5-1 h 1.5-4 h Carisoprodol 15 min 1.5-2 h 2.5 hChlorzoxazone 20 min 1-2 h 1.1 h Cyclobenzaprine 20 min 1-2 h 8-37 hMethocarbamol 20 min 1-2 h 1-2 h Metaxalone 35 min 3 h 5-12 hOrphenadrine 25 min 2 h 13-20 h Soma 20 min 1.5-2 h (metabolite) 10 h(metabolite) 2-4 h *Release of mechanoreceptor neuromodulator,GUA—Guaifenesin, is designed via standard testing of formulations indissolution media as described in USP guidances. PSE—pseudoephedrineimmediate release designed with same dissolution profile as CNS drug.

EXAMPLES

The following examples illustrate the effectiveness of the compositionsand methods of the present invention. Other suitable modifications andadaptations to the variety of conditions and parameters normallyencountered in clinical therapy, and which are obvious to those skilledin the art, are within the spirit and scope of the invention.

Example 1

A 42-year-old male patient had experienced tooth pain. The patient wasgiven the following treatment: at 11:00 a.m.-co-administration of Soma(Carisoprodol) with 60 mg of Pseudoephedine. At 11:10 a.m.-600 mg ofGuaifenesin. The patient reported less pain than prior to the procedure,without any sedation or other side-effects. At no time during thetreatment did the patient feel somnolent or have any desire to sleep.

Example 2

A 40-year old healthy female volunteer was prescribed 250 mg two times aday Soma by her family doctor for reduction of lower back pain. Duringthe treatment, the volunteer suffered from the sedative side-effect ofSoma. It was suggested to the volunteer that she try taking the Soma inconjunction with the synchronized vagal neuromodulation treatment of thepresent invention over two days but not before sleep time. The volunteeragreed to take Soma during the day together with the neuromodulationtreatment. She took Soma in the morning and afternoon together withPseudoephedrine followed 15 minutes later by Guaifenisin. Significantly,during the day, the volunteer reported that she did not feel sedatedduring this two-day regimen and back pain was effectively reduced.

Example 3

Seroquel is primarily used to treat psychotic symptoms in doses of400-700 mg daily, with side-effects of headache, dry mouth, as well asother side-effects. To establish that the pharmaceutical compositionreduces the sedative side-effects of CNS active agents, a non-blindclinical trial with 5 volunteers was carried out using Seroquel. Overthe course of sequential weeks, each participant took one dose of thefollowing:

Dosage (mg): 400 mg Seroquel; 60 mg Pseudoephedrine (PED-sinufed); 600mg Guaifenesin (GUA-Mucinex) in the manner outlined below:

-   -   1. Control Treatment (CT): At time t: 400 mg Seroquel;    -   2. Double Cocktail Treatment (DCT-PSE): At time t:        Seroquel+Pseudoephedrine (PSD);    -   3. Double Cocktail Treatment (DCT-GUA): At time t: Seroquel. At        time t+30 min: Guaifenesin (GUA);    -   4. 4. Triple Cocktail Treatment (TCT): At time t:        Seroquel+Pseudoephedrine (PSD) At time t+30 min: Guaifenesin        (GUA);    -   5. Triple Cocktail Treatment, No Delay (TCT-ND): At time t:        Seroquel+Pseudoephedrine (PSD)+Guaifenesin (Immediate        release-IR-layer only).

Results were tabulated following a brief interview, consisting of anumber of simple questions. While more qualitative than quantitative,the results provide a good preliminary indication of the efficacy of theproposed formulations. Following analysis, the result of the study wasthat the triple cocktail treatment (TCT) had a better side-effectsprofile as measured by the level of sedation when compared to either thecontrol treatment (CT), or the double cocktail treatments (DCT-PSE;DCT-GUA), or the No Delay Triple Cocktail (TCT-ND.

Example 4

During a first test, the subject reported that he took Flunitrazepam 0.5mg at 1 PM and 15 minutes later ingested pseudoephedrine 60 mg andMucinex 600 mg. (Mucinex tablets have IR layer and a delayed releaselayer. For this arm of the experiment, the IR layer was manuallyseparated from the tablets. Each tablet consists of 600 mg,approximately ¼ of which is IR, by weight. In order to insure asufficient dose of IR Guaifenesin was available, 5.5 g of IR Guaifenesinwas separated. Each dose administered was ˜900 mg Guaifenesin). For thefirst three hours he felt a little “loopy”. By the start of the fourthhour he felt perfectly normal. He reported that he has not beensuffering from any significant anxiety so he cannot comment on whetherit had an anxiolytic effect or not. At no time during the treatment didhe feel somnolent or have any desire to sleep.

During a second test, approximately a week after the first test ofFlunitrazepam, the subject reported that he took Flunitrazepam 1.0 mg at11:50 AM and at the same time ingested pseudoephedrine 60 mg and Mucinex600 mg. For the first 45 minutes to an hour he felt perfectly finewithout any unusual feelings. By the second hour he started to feeltranquilized which continued through the end of the sixth hour. At theend of the sixth hour he again felt perfectly normal without any unusualfeelings. He reported that he has not been suffering from anysignificant anxiety so he cannot comment on whether it had an anxiolyticeffect or not. At no time during the experiment did he feel somnolent orany desire to sleep.

Example 5

The subject reported that he took Lorazepam 1 mg and pseudoephedrine 60mg at 12 noon and 15 minutes later ingested and Mucinex 600 mg. For thefirst three hours he felt a little “loopy”. By the start of the fourthhour he felt perfectly normal. He reported that he has not beensuffering from any significant anxiety so he cannot comment on whetherit had an anxiolytic effect or not. At no time during the experiment didhe feel somnolent or any desire to sleep.

Example 6

Volunteer A, a 34 year old healthy male (1.83 cm, 95 Kg), was prescribed1 mg Lorazepam (BDR) by his family doctor for anxiety and anxietyrelated insomnia. Volunteer

A took Lorazepam in conjunction with the neuromodulators to reduceLorazepam's associated sedative side-effects. Volunteer A, who felt hisanxiety peak particularly on weekends, agreed to take Lorazepam duringthe day together with the neuromodulators. When taking Lorazepam alone,Volunteer A reported that his anxiety was ameliorated, but he wasseverely sedated, sleeping over 3 hours in an afternoon. When takingLorazepam together with pseudoephedrine, Volunteer A reported being assedated as with Lorazepam alone, yet upon waking felt much less anxiousthan without treatment. When taking Lorazepam followed 15 minutes laterby Guaifenesin, Volunteer A reported feeling somewhat sedated yet“hostile and anxious”. When taking Lorazepam simultaneously withPseudoephedrine, Guaifenesin and, Volunteer A was sedated and lessanxious. Significantly, when taking 1 mg Lorazepam together withPseudoephedrine followed by Guaifenesin after 15 minutes, Volunteer Adid not feel sedated and reported feeling at ease and anxiety free.

This demonstrates synchronization of Tmax of Lorazepam Pseudoephedrine,and Guaifenesin by having local mechanoreceptors affected by vagalneuromodulation. BDZ's side-effects were reduced while retaining BDZ'sanxiolytic activity.

Example 7

The purpose of this example was to determine if the co-administration ofpseudoephedrine and guaifenesin with alprazolam has effective inreducing the sedation commonly seen with the administration ofalprazolam alone.

The research study was performed on four healthy volunteers, ages 25-41years old and 60-75 kg. The study was carried out in two sessions withone week in between. During the study volunteers completed a test tomeasure sleepiness by Stanford Sleepiness Scale (SSS). This SSS test wasdone before doses of the compositions being evaluated and 2, 4 and 6hours after such doses (see FIG. 5 for an illustration of the studyscheme).

At the first session, volunteers received the treatment (Alprazolam 1.0mg)+PLAC (placebo)+ and 15 minutes later another PLAC. During thissession, all four subjects were asleep within an hour and a half. Onepatient woke up for the 2 hour time point test, but then fell backasleep and did not awaken for the 4 and 6 hour testing. His SSS score at2 hour time point was 6 (woozy, fighting sleep). A second patient sleptthrough the 2 hour point but took the test at 4 hours (SSS score was 6)and then fell back asleep and did not awaken for the 6 hour test. Theother 2 patients slept through the 2, 4 and 6 hour testing.

At the second study session, volunteers received the treatment(Alprazolam 1.0 mg+60 mg of pseudoephedrine) and 15 minutes laterreceived 400 mg of guaifenesin. During this session, all four subjectswere asleep within an hour and a half and missed the 2 hour time pointtest. After 2 and half hours, three out of the four subjects woke up andstayed awake for the rest of the time. Their SSS scores for 4 hour timepoint test were 2, 3 and 5, for 6 hour time point test SSS scores were1, 3, 2. The fourth subject woke up for the 6 hour time point test andhis SSS score was 3.

Thus, total sleep time for each subject during first session (Alprazolamadministrated with placebo) was 5-6 hours for 3 patients and about 2hours for 4th patient. During second session (Alprazolam administratedwith neuromodulators) total sleep time for all for patients was 1.5-2.5hours only. These results (TABLE 7; FIG. 6) indicate that synchronizedadministration of Alprazolam with neuromodulators effectively reducesthe sedation effect of Alprazolam.

TABLE 7 SSS measurements on subjects receiving alprazolam. SubjectPre-Dose SSS 2 Hr SSS 4 Hr SSS 6 Hr SSS First Visit Day on Placebo 101 1X - asleep X - asleep X - asleep 102 3 X - asleep 6 X - asleep 103 1 X -asleep X - asleep X - asleep 104 1 6 X - asleep 3 Second Visit Day onActive Neuromodulation 101 1 X - asleep 2 1 102 2 X - asleep X - asleep3 103 1 X - asleep 5 3 104 1 X - asleep 3 2

Example 8

The following clinical feasibility trial took place over the course of 8weekends from April to August. The purpose of the study was to determinethe efficacy of Pseudoephedrine (PED) and Guaifenesin (GUA) given inconjunction with 1-1.5 mg Lorazepam in reducing Lorazepam's sedativeside-effects. The study design has: Non-blinded, cross-over efficacystudy (volunteers 2, 3, 4); and Single blinded cross-over efficacy study(volunteers 1 & 5). The five participants were generally healthyvolunteers (see TABLE 8).

TABLE 8 Age, weight, and gender of volunteers in Example 8. Participantno. Gender Age Weight (kg) 1 Male 41 90 2 Male 36 80 3 Male 34 94 4Female 40 66.5 5 Female 38 52

On sequential weekends, either on a Friday or a Saturday between 12 and2 pm, each participant took one dose of the following:

Dosage (mg):

-   -   Participant nos. 1 and 3-1.5 mg Lorazepam    -   Participant nos. 2, 4, and 5-1 mg Lorazepam    -   All participants—60 mg Pseudoephedrine (PED-Sinufed)    -   All participants—600 mg Guaifenesin (GUA-Mucinex)

Mucinex tablets have an IR layer and a delayed release layer. For thisstudy, the IR layer was manually separated from the tablets. Each tabletconsists of 600 mg, approximately ¼ of which is IR, by weight. In orderto insure a sufficient dose of IR Guaifenesin was available, 5.5 g of IRGuaifenesin was separated. Each dose administered was ˜900 mgGuaifenesin.

-   -   1. Control Treatment (CT): At time t: 0 mg (no. 2,4, & 5)/1.5        (no. 1 & 3) Lorazepam    -   2. Double Cocktail Treatment (DCT-PSE): At time t:        Lorazepam+Pseudoephedrine (PSD)    -   3. Double Cocktail Treatment (DCT-GUA): At time t: Lorazepam; At        time t+30 min: Guaifenesin (GUA-Mucinex)    -   4. Triple Cocktail Treatment (TCT): At time t:        Lorazepam+Pseudoephedrine (PSD); At time t+30 min: Guaifenesin        (GUA-Mucinex)    -   5. Triple Cocktail Treatment, No Delay (TCT-ND): At time t:        Lorazepam+Pseudoephedrine (PSD)+Guaifenesin (Immediate        release-IR— layer only.

Results were tabulated following a brief interview, consisting of anumber of simple questions (See TABLES 9-14). While more qualitativethan quantitative, the results provide a good preliminary indication ofthe efficacy of the proposed formulations.

TABLE 9 Question (1) On a scale of 1-10 (1 = wide awake, 10 = extremelytired), how sleepy were you following the treatment? Question (2) Didyou fall asleep? Participant No. CT DCT-PSE DCT-GUA TCT TCT-ND 1 10 Y 8Y 10  Y 1 N 7 N 2 6 N NA NA 7 Y 1 N 9 Y 3 8 Y 2 N 9 Y 3 N 8 Y 4 10 Y 8 Y9 Y 2 N 8 N 5 8 Y 7 Y 9 Y 2 N 9 Y Mean 8.4 ± 1.6 Y = 80% 6.2 ± 2.9 Y =75% 8.8 ± 0.9 Y = 100% 1.8 ± 0.9 Y = 0 8.2 ± 0.8 Y = 60% N = 20% N = 25%N = 0 N = 100% N = 40%

TABLE 10 Question (3) On a scale of 1-10 (1 = Stressed, 10 = Veryrelaxed), how relaxed were you following the treatment? Participant No.CT DCT-PSE DCT-GUA TCT TCT-ND 1 8 5 10 10 9 2 9 NA 8 10 10 3 9 3 9 9 8 410 3 6 10 10 5 9 6 9 9 8 Mean 9 ± 0.7 4.25 ± 1.5 8.4 ± 1.4 9.6 ± 0.5 9 ±1

TABLE 11 Question (4) Following treatment, did you feel worried?Participant No. CT DCT-PSE DCT-GUA TCT TCT-ND 1 N Y N N N 2 N NA N N N 3N Y N N N 4 N Y N N N 5 N N N N N Result No = 100% Yes = 75% No = 100%No = 100% No = 100% No = 25%

TABLE 12 Question (5) Following treatment, did you feel anxious?Participant No. CT DCT-PSE DCT-GUA TCT TCT-ND 1 N Y N N N 2 N N N N N 3N Somewhat N N N 4 N Y N N N 5 N N N N N Result No = 100% No = 50% No =100% No = 100% No = 100% Yes = 50%

TABLE 13 Question (6) Following treatment, did you experience any otherform of physical discomfort? Participant No. CT DCT-PSE DCT-GUA TCTTCT-ND 1 N N N N N 2 N N N N N 3 N N N N N 4 N N N N N 5 N N N N N

TABLE 14 Question (7) Following treatment, did you have troubleconcentrating? Participant No. CT DCT-PSE DCT-GUA TCT TCT-ND 1 Y Y Y N N2 Y N N N N (fell asleep) 3 Y N N N Y 4 Y Y N N Somewhat 5 Y N N N Y(fell asleep) Result Yes = 100% Yes = 40% Yes = 20% No = 100% Yes = 70%No = 60% No = 80% No = 30%

In summary, the results indicate that: Compared to the control treatment(CT), the triple cocktail treatment (TCT) showed comparable efficacy interms of stress and anxiety reduction (Questions 3-5). Compared to thecontrol treatment (CT), the PSE double cocktail treatment (DCT-PSE)exhibited reduced efficacy in terms of stress and anxiety reduction(Questions 3-5). The GUA double cocktail treatment (DCT-GUA) and theundelayed triple cocktail treatment (TCT-ND) exhibited comparableefficacy to the control treatment in terms of stress and anxietyreduction. Compared to the control treatment (CT), the double cocktailtreatments (DCT-PSE; DCT-GUA) and the No Delay Triple Cocktail (TCT-ND),the triple cocktail treatment (TCT) had a better side-effects profile asmeasured by the level of sedation (Questions 1-2), and the ability toconcentrate (Question 7). In addition, none of the treatments resultedin physical discomfort (Question 6).

Example 9

The purpose of this study was to determine if the co-administration ofpseudoephedrine and guaifenesin with lorazepam is effective in reducingthe sedation commonly seen with the administration of lorazepam alone.The research study was performed on four healthy volunteers ages 25-41years old and 60-75 kg. The study was carried out by two sessions with aone-week interval between the sessions. During the study volunteerscompleted a set of tests to measure sleepiness by the StanfordSleepiness Scale (SSS). This test was done before doses of study drugand 2, 4 and 6 hours after doses of study drug (see FIG. 5 for anillustration of the study scheme).

At the first study session volunteers received the treatment (Lorazepam1.0 mg)+PLAC (placebo)+ and 15 minutes later another PLAC. During thissession one of the four subjects was asleep within a half hour and sleptfor three hours. He stayed awake at the 4- and 6-hour time points. HisSSS scores were 2. Two subjects were asleep in one hour. One of themslept 3.5 hours, his SSS at the 6-hour time point was 2. The secondsubject slept 2.5 hours, and his SSS scores for both the 4- and 6-hourtime points were 2. One subject was asleep in one and a half hours andslept for 1 hour 15 minutes. He remained awake at the 4- and 6-hour timepoints. His SSS scores were 2.

At the second study session volunteers received the treatment (Lorazepam1.0 mg+60 mg of pseudoephedrine) and 15 minutes later received 400 mg ofguaifenesin. During this session all four subjects remained awake mostof the time. One patient stayed awake throughout the study, and his SSSscores were 3 for all time points. The second subject was asleep withinan hour and a half and slept for half an hour. He missed the 2-hour timepoint measurement, and his SSS scores for the 4- and 6-hour time pointswere 2 and 3, respectively. The third subject was asleep within a hourand half and slept for 15 minutes. His SSS score for 2-hour time pointwas 2. This subject was asleep again within 3 and a half hours and sleptfor one hour. He missed the 4-hour time point, but was awake formeasurements at the 6-hour time point (SSS was 2). The fourth subjectwas asleep within an hour and slept for half an hour. He stayed awakethe rest of the time, and his SSS scores for the 2-,4-, and 6-hour timepoints were 3,2,3 respectively. Results of this study are presented inTABLE 15 and FIG. 6.

Thus, the total sleep time for each subject during the first session(Lorazepam administrated with placebo) was 3-3.5 hours for 2 patients,about 2 hours for one patient, and about 1 hour for one patient. Duringthe second session (Lorazepam administrated with neuromodulators), totalsleep time for one subject was an hour and a half, 30 minutes for twosubjects, and one subject did not slept at all.

Taken together those results strongly indicate that synchronizedadministration of Lorazepam with neuromodulators effectively reducessedation effect of Lorazepam.

TABLE 15 SSS measurements on subjects receiving lorazepam. SubjectPre-Dose SSS 2:00 SSS 4:00 SSS 6:00 SSS First Visit Day on Placebo 105 2X - Asleep 2 2 106 2 X - Asleep 3 2 107 2 X - Asleep X - Asleep 2 108 2X - Asleep 2 X - Asleep Second Visit Day on Active Neuromodulation 105 23 3 3 106 1 X - Asleep 2 3 107 1 2 X - Asleep 2 108 2 3 2 3

Investigational Studies Rationale

PSE (as a chemoreceptor stimulator) and GUA (as mechanoreceptorstimulator) were used to reduce the sedative side-effects of Lorazepam,a commonly used anxyolytic agent with sedative properties, Quetiapine(Seroquel) an atypical antipsychotic commonly prescribed for thetreatment of schizophrenia and bi-polar disorder, and SOMA a musclerelaxant commonly used for the treatment of acute muscle pains. In eachstudy, a number of volunteers (N=6) took the medication on consecutiveweeks, with a minimum washout period of 7 days between treatments. Eachstudy had a number of arms: (1) drug alone, (2) drug with NMI (PSE), (3)drug with NM2 (GUA), (4) drug with both NM's, taken withoutsynchronization, and finally the experimental arm, (5) drug with bothNM's synchronized with the t-max of the drug.

With the CNS active agent alone, desired results of reduction ofsedation side-effects were not obtained. However, the combined CNSactive agent comprising both chemoreceptor stimulator (PSE) andmechanoreceptor stimulator (GUA) was effective in reduction of thesedation outcome without disturbing anti-stress action of the drugs. Inaddition, delayed administration of GUA (at least for 10-30 minutes,preferably 15-20 minutes) was significant to synchronize between PK andPD of CNS active agent and neuromodulators.

Having herein set forth various and preferred embodiments of the presentinvention, it is anticipated that suitable modifications can be madethereto which will nonetheless remain within the scope of the invention.The invention shall therefore be construed in accordance with the claimsthat follow.

Example 10

This research study was designed to determine the safety and feasibilityof using open-label, low dose alprazolam for the treatment of GAD. Thepurpose of this investigation was to demonstrate the continuing efficacyof neuromodulated alprazolam and the reduction of sedation-relatedeffects associated with alprazolam with the concomitant administrationof pseudoephedrine and guaifenesin in GAD or PD patients. In addition,quality of life was measured. Safety and tolerance of the productcombination was assessed simultaneously.

The study was a single blind trial in which a panel of 8 patientssuffering from GAD were administered alprazolam (1 mg), pseudoephedrine(60 mg), and guaifenesinER (600 mg). Subjects underwent an initialscreening and then two weeks of testing with the medications of thestudy (see FIG. 7 for an illustration of the study scheme). Fourteendays prior to the first treatment session, subjects were screened with astandard medical/psychiatric history and physical exam (Screening Visit,Visit 1). Standard laboratory tests were performed at Screening Visit 1including those of chemistry, hematology and urinalysis, urine test fordrugs of abuse, HIV and hepatitis B and C serology tests, 12-leadresting electrocardiogram, and serum pregnancy test for females.

Prior to administration of the placebo treatment, the subjects wererated on the Hamilton Anxiety Scale, Quality of Life Questionnaire, andthe Stanford Sleepiness Scale (SSS) (Visit 2, data not shown). Subjectscomplained of oversedation (SSS score of 4 or greater) from theirpsychopharmacologic regimen, which included benzodiazepine or alprazolamtherapy.

Subjects were given a placebo medication that mimics the twoneuromodulators for 7 days and underwent another series of tests at theend of this 7-day period (Visit 3). The subjects were asked to ratetheir sleepiness on the SSS two hours and four hours after each dose ofalprazolam (data not shown). Thereafter, the subjects were given theactive neuromodulators and told to start with them on the next dayfollowing ingestion of their regular alprazolam medication. The subjectstook pseudoephedrine with alprazolam and Mucinex 15 minutes later(neuromodulators were given no more than twice a day and not after 6PM). Three hours after each dose, patients were asked to rate theirsleepiness on the SSS.

After one week (Visit 4) on alprazolam and the neuromodulators, thesubjects were again were rated on the Hamilton Anxiety Scale, Quality ofLife Questionnaire and SSS. Each day throughout the study, the subjectswere asked to rate their sleepiness on the SSS 3 hours after ingestionof each alprazolam dose.

Results (not shown) suggest that the efficacy of alprazolam was notaffected by the combination treatment as measured by the HamiltonAnxiety Scale. Furthermore, sedation-related effects associated withalprazolam were significantly reduced as measured by the SSS.

Example 11

The purpose of this investigation was to demonstrate the continuingefficacy of neuromodulated alprazolam, the reduction of sedation-relatedeffects associated with alprazolam (ALP) with the concomitantadministration of pseudoephedrine and guaifenesin in patients sufferingfrom GAD.

The study was performed on one GAD patient, a 25 year-old female.Fourteen days prior to the first treatment session, the subject wasscreened with a standard medical/psychiatric history and physical exam.The subject was rated on the Hamilton Anxiety Scale the StanfordSleepiness Scale (SSS).

During her second visit, immediately prior to administration ofalprazolam and placebo, the subject was rated on the Hamilton AnxietyScale, Quality of Life Questionaire and SSS (pre dose, time 0).Following these tests, the subject received a regular morning alprazolamdose and placebo to mimic pseudoephedrine. Fifteen minutes later, thesubject received approximately 120 ml of water and placebo to mimicguaifenesin. The subject was rated on the SSS at 2 hours (anticipatedpeak plasma concentration) and 4 hours following administrationalprazolam. The subject was given enough placebo medication to last forone week (until Visit 3) with the exact instructions to take theirmedications in the same manner as described above. During this 7-dayperiod, the subject completed an SSS questionaire (Table 16, Placebo).Ratings on the SSS were recorded immediately before (pre) and 3 hoursfollowing (post) administration of alprazolam. Results indicatesignificantly reduced alertness and increased sedation.

During Visit 3, the subject was rated on the Hamilton Anxiety Scale,Quality of Life Questionaire, and SSS 3 hours after initial dose. Thesubject was then given the active neuromodulators and told to start withthem on the next day following ingestion of the regular alprazolammedication. The subject took pseudoephedrine with alprazolam and Mucinex15 minutes later (neuromodulators were given no more than twice a dayand not after 6 PM). Three hours after each dose, the subject recordedher SSS measurements (Table 16, Treatment). During this week oftreatment, the subject's SSS data indicate dramatic improvement relativeto the placebo treatment. Throughout this week, the subject recorded SSSscores of 1 (high alertness, no sedatition). Data based on the SSSobservations are presented in TABLE 16. Additionally, observations basedon the Hamilton Anxiety Scale did not show any reduction in the efficacyof the alprazolam medication.

The results of the studies performed in examples 10 and 11 suggest thatconcomitant administration of pseudoephedrine and guaifenesin withalprazolam reduce sedation-related effects associated with alprazolamwithout affecting the therapeutic efficacy of the drug in GAD patients.

TABLE 16 SSS scale observations of subject studied in Example 11.Placebo Treatment Location Time SSS Score Location Time SSS Score 3 hpost X - asleep dose Screen 6 Clinic Day 1 pre 5 Clinic Day 8 post 1Clinic Day 1 post X - asleep Home Day 3 pre 1 Home Day 10 pre 1 Home Day3 post X - asleep Home Day 10 post 1 Home Day 5 pre 1 Home Day 12 pre 1Home Day 5 post X - asleep Home Day 12 post 1 Home Day 7 pre 1 Home Day14 pre 1 Home Day 7 post X - asleep Home Day 14 post 1 Clinic Day 8 pre1 Clinic Day 15 pre 1 Clinic Day 15 post 1

What Is claimed Is:
 1. A method of reducing a side-effect of a centralnervous system (CNS) active agent, the method comprising: administeringat least one CNS active agent to a patient; and administering at leasttwo vagal neuromodulators to the patient in an amount sufficient toreduce a side-effect of the CNS active agent, wherein at least oneneuromodulator is administered or released at least about 5 minutesafter the CNS active agent is administered or released.
 2. The method ofclaim 1, wherein the side-effect is at least one side-effect selectedfrom the group consisting of: sedation, somnolence, sleepnece, memoryimpairment, amnesia, impairment of cognitive and learning function,ataxia, impaired night sleep/day alertness, impaired memory, impairedconcentration, impaired appetite, drowsiness, hypotension, fatigue,kinetic disorders, catalepsy, movement disorders, bowel irritation andimpaired reaction.
 3. The method of claim 2, wherein the side-effect issedation.
 4. The method of claim 1, wherein CNS agent is in an amountthat is substantially the same as the conventially accepted effectivedosage.
 5. The method of claim 4, wherein the at least two vagalneuromodulators comprise at least one mechanoreceptor stimulator and atleast one chemoreceptor stimulator.
 6. The method of claim 5, whereinthe mechanoreceptor stimulator is guaifenesin (GUA).
 7. The method ofclaim 6, wherein the GUA is released about 10 to about 20 minutes afterthe release of the CNS active agent.
 8. The method of claim 7, whereinthe chemoreceptor stimulator is selected from the group consisting of:pH modulators, secretagouges, adrinomimetics, xanthines,cholecystokinins and gastric agonists.
 9. The method of claim 8, whereinthe chemoreceptor is pseudophedrine (PSE).
 10. A method of reducing aside-effect of a central nervous system (CNS) active agent, the methodcomprising: administering at least one CNS active agent; andadministering to the patient at least two vagal neuromodulatorscomprising at least one mechanoreceptor stimulator, wherein the at leasttwo vagal neuromodulators are in an amount sufficient to reduce theside-effect associated with the CNS active agent.
 11. The method ofclaim 10, wherein release or the administration of the mechanoreceptorstimulator is delayed.
 12. The method of claim 10, wherein the CNSactive agent has a time to maximum concentration (Tmax) and themechanoreceptor stimulator has a Tmax, the delay in the administrationor release of mechanoreceptor stimulator being equal to the Tmax of theCNS active agent minus the Tmax of the mechanoreceptor stimulator plusabout 5 to about 30 minutes.
 13. The method of claim 10, wherein the atleast two vagal neuromodulators comprise at least one chemoreceptorstimulator selected from the group consisting of: pH modulators,secretagouges, adrinomimetics, xanthines, cholecystokinins and gastricagonists.
 14. The method of claim 10, wherein the mechanoreceptorstimulator is selected from the group consisting of: mucomodulators andsurfactants.
 15. The method of claim 14, wherein the mechanoreceptorstimulator is guaifenesin (GUA).
 16. The method claim 15, wherein the atleast two vagal neuromodulators comprises pseudophedrine (PSE).
 17. Themethod of claim 15, wherein the GUA is administered about 5 to about 30minutes after administration of the CNS active agent.
 18. The method ofclaim 10, wherein the side-effect is at least one selected from thegroup consisting of: sedation, somnolence, sleepnece, memory impairment,amnesia, impairment of cognitive and learning function, ataxia, impairednight sleep/day alertness, impaired memory, impaired concentration,impaired appetite, drowsiness, hypotension, fatigue, kinetic disorders,catalepsy, movement disorders, bowel irritation and impaired reaction.19. The method of claim 18, wherein the side-effect is sedation.
 20. Themethod of claim 19, wherein the side-effect is reduced without reducingefficacy of the CNS active agent or the conventionally acceptedeffective dosage.